Globally, men who have sex with men (sometimes referred to as MSM) are 19 times more likely to be living with HIV than the general population. This figure is rising in some regions such as Asia.
During 2011, men who have sex with men accounted for 41% of new HIV infections in Western Europe, 56% in Peru and 63% in the United States of America (USA). In Jamaica, one in three men who have sex with men are living with HIV.
What factors put men who have sex with men at risk of HIV?
The fact that HIV prevalence among men who have sex with men is so high in many countries means that members of this group have an increased chance of being exposed to the virus, due to mainly having sexual relations within this group. However, there are also other factors that put men who have sex with men at heightened risk of HIV.
One major reason for high vulnerability to HIV among this group is that unprotected anal sex carries a higher risk of transmission than vaginal sex. This is because the walls of the anus are thin and more easily torn, creating an entry point for HIV into the bloodstream.
Having a sexually transmitted infection (STI) also makes a person more susceptible to HIV infection. Among men who have sex with men, HIV testing and sexual health check-up frequency is low (less than 55% across all regions). This means that many are living with an undiagnosed STI which may put them at higher risk of HIV.
Men who have sex with men are often not aware of the particularly high risk of having unprotected sex with a person who has recently become infected. In London, United Kingdom (UK), a study reported that 27% of infections among men who have sex with men were from a partner recently infected with HIV.
Having multiple sexual partners is more common among this community, and many do not use condoms consistently. In fact, men who have sex with men reporting easy access to condoms in 2012 varied from 29% in upper-middle income countries, to 45% in high-income countries, meaning that access to condoms worldwide remains inadequate for this group.
Like condom access, HIV testing access is equally low, ranging between 25% and 54% across the world. By not testing for HIV, many men who have sex with men are unaware of their HIV status which can mean they are unaware of the need to take protective measures to prevent onwards transmission to others. For example, a study in India found that only 30% of a cohort of more than 1,000 men who have sex with men living with HIV were aware of their HIV-positive status.
Alcohol and drugs are a common part of socialising in some communities of men who have sex with men. Whenever drink and drugs are taken, it can make it more likely that people will have unprotected sex and a higher number of sexual partners, elevating vulnerability to HIV.
Men who have sex with men living with HIV often become HIV-positive while still young. Estimates suggest that 4.2% of young (under 25 years) men who have sex with men are living with HIV. This is more common in countries where HIV prevalence among the whole men who have sex with men population is quite high. It is also harder for young men who have sex with men to access HIV services, due to age of consent laws or unsociable opening times. For example, HIV testing and status awareness in 2014 was lower among young men who have sex with men (36%) than among this group as a whole (43%).
As of May 2016, a third of countries around the world (75) still criminalise same-sex conduct, affecting the rights of men who have sex with men and other members of the LGBT community. In countries such as Iran, Sudan, Saudi Arabia and Yemen homosexuality is punishable by the death penalty. As a result, men who have sex with men are less likely to access HIV services for fear of their sexual orientation and identity being revealed.
In many countries ‘homosexual propaganda’ is now banned too. Such laws have been introduced in countries such as Russia and Nigeria to ‘support’ homophobic laws, to prevent the promotion of homosexuality to the public and children in particular. The exact meaning of these laws is confusing, and LGBT rights groups and non-governmental organisations (NGOs) working with this community have been punished under homosexual propaganda laws for helping ‘promote’ homosexuality.
Russian-style propaganda laws are also being proposed in Ukraine, Belarus, Bulgaria, Latvia, Kazakhstan and Kyrgyzstan. In addition, there are a further 13 states in the Middle East and North Africa where ‘morality laws’ actively target public promotion or expression of same-sex and trans realities.
Social and cultural factors
Many men who have sex with men have experienced homophobic stigma, discrimination and violence. This drives men who have sex with men to hide their identity and sexual orientation. Many fear a negative reaction from healthcare workers. As a result, men who have sex with men are less likely to access HIV services.
Men who have sex with men are more likely to experience depression due to social isolation and disconnectedness from health systems. This can make it harder to cope with aspects of HIV such as adherence to medication.
HIV prevention programmes for men who have sex with men
High HIV prevalence among men who have sex with men around the world is evidence that prevention strategies are failing to reach this group.
Reports from 20 countries in 2009 and 2013 show that the percentage of men who have sex with men reached by HIV prevention programmes fell from 59% to 40%. However, access varies greatly between regions and within countries. For example, men who have sex with men on a higher income are more likely to be able to afford, and therefore access prevention initiatives, than those on a low income.
When men who have sex with men are targeted by HIV prevention campaigns they can be extremely effective. It is important that a combination of prevention programmes are available.
In recognition of this, in 2015, a group of international agencies and non-governmental organisations (NGOs) released a tool for use by public health officials, HIV and STI programmes officials, NGOs (both international and community-based) and health workers.
The tool, Implementing Comprehensive HIV and STI Programmes with Men Who Have Sex with Men, provides recommendations for HIV prevention, testing and treatment for men who have sex with men and is based on successful community-led approaches.
Condoms and lubricants
One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible to men who have sex with men.
In some countries, gay bars and other known meeting places for men who have sex with men, such as bathhouses, provide and promote condoms and lubricants. The Blue Sky Club is a civil society group in Vietnam that provides ‘edutainment’ events in local bars and clubs, combining HIV education and condom distribution with entertainment events, which are well received by local men who have sex with men. Providing these in gay-friendly places is much more effective than expecting men who have sex with men to purchase them from pharmacies, or healthcare settings that they may be fearful of visiting.
Many of the most successful HIV programmes aimed at men who have sex with men empower this group and actively involve them in a community setting.
In sub-Saharan Africa, studies have shown how HIV services that are targeted at, and run by men who have sex with men, have seen the greatest response and uptake. This avoids the necessity of attending general healthcare settings, where men who have sex with men risk identity and sexual orientation exposure that could be met with stigma and discrimination.
Training peers who are part of the men who have sex with men population to educate others, provide prevention commodities and link people to MSM-friendly HIV services has been shown to effectively reach and engage this population. This prevention strategy works on the basis that there is an elevated sense of trust between members of the men who have sex with men population, whereby fear of stigma is eradicated. Organisations staffed by men who have sex with men are also more credible and accessible to recipients.
In the Philippines, one initiative attempted to help civil society engage with local government in the HIV response. Eighteen community-based groups were set up and 200 men who have sex with men and transgender people were trained in sexual health and rights. After three years, community leadership led to dialogue with local government officials on HIV, gender and human rights issues. One outcome of this process was an anti-discrimination ordinance in the city of Cebu in 2012 which prohibits discrimination on the basis of sexual orientation, gender identity and health status (including HIV).
HIV testing initiatives
Two of the most effective ways to encourage HIV testing among men who have sex with men are to permit home-based testing, and provide community-based testing.
Home-based testing has the benefit of the user being able to avoid identification by healthcare workers. The privacy of conducting an HIV test alone at home is very favourable among men who have sex with men for this reason. One study in Brazil found that 90% of men who have sex with men participants would use self-testing kits, although concerns included receiving the result alone and being able to read the result properly. Men who have sex with men should be educated about the use of self-testing kits, to heighten their confidence in using one if they are unwilling to test at regular healthcare settings.
Community-based testing at local pop-up clinics or mobile vans is also favoured among men who have sex with men. It means that they can access testing in a setting they are comfortable in, without having to travel to clinics where they may be seen or experience discrimination.
PrEP and PEP
Recent research has shown that pre-exposure prophylaxis (PrEP) can reduce HIV transmission among men who have sex with men by 92%. The World Health Organization (WHO) states that if its use is scaled up, an estimated 20% to 25% of new HIV infections among this population could be prevented.
PrEP is a single pill taken every day by people who are at risk of HIV exposure, such as men who have sex with men. However, it is stressed that in order for the preventative effects to be realised, it must be taken correctly and consistently, alongside using condoms. Men who have sex with men should be counselled and informed about the correct use of PrEP before it is offered. Despite expanding evidence of its effectiveness in HIV prevention, as of June 2016, PrEP was being implemented in only six countries.
By contrast, post-exposure prophylaxis (PEP) is taken after potential exposure to HIV. WHO recommends offering PEP to men who have sex with men as part of a package of prevention options. It must also be coupled with counselling about the importance of finishing the treatment course. One study found that only 67% of men who have sex with men on average completed the 28 day course, limiting the effectiveness of PEP.
Due to the preference for anonymity when it comes to accessing healthcare, some studies have shown that technology, messaging, and social media have helped to provide HIV prevention information to men who have sex with men.
One study in South Africa found that sending text messages to men who have sex with men over a period of time encouraged men to test for HIV. The Adam’s Love organisation in Bangkok, Thailand, used a dedicated website, social media and web message boards for online counselling, recruitment and appointment making. Between September 2011 and January 2015, over 11,000 men who have sex with men received online counselling while over 8,000 were referred to HIV testing services.
These types of programmes should be further explored as an avenue to engage men who have sex with men in the HIV response and their own healthcare.
Access to antiretroviral treatment for men who have sex with men
Currently, data on HIV treatment access among men who have sex with men is very limited. Worldwide, only 40% of men who have sex with men living with HIV are thought to be accessing treatment. Reasons cited for such low access include homophobia, stigma and discrimination. These can cause men who have sex with men to delay, interrupt or avoid treatment altogether. Experiencing these reactions from healthcare workers is also given as a predominant reason.
Likewise, information on treatment retention rates is also scarce. However, one study that recruited 6,095 men who have sex with men from 145 countries reported a drop-off at every point along the treatment cascade. Drop-off was particularly dramatic among young men who have sex with men and men who have sex with men in lower-income countries. This was due to a lack of investment and youth-friendly services. By contrast, comfort with provider, more community engagement and better accessibility of ART were associated with higher retention rates in care.
Barriers to HIV prevention programmes for men who have sex with men
High-risk sexual behaviour
Due to widespread stigma, many men who have sex with men want to keep their sexual orientation secret, and may also continue to have heterosexual relationships and even get married. In Asia and the Pacific between 2003 and 2007, 21% to 42% of men who have sex with men were married.
Many men who have sex with men have a low risk perception of HIV as a result of not being included in sex education classes in school, and not being reached with HIV prevention initiatives. Having multiple partners is also more common among this community, with alcohol and drug abuse fuelling high-risk sexual behaviour such as not using a condom.
One internet survey found that 32% of men reported having unprotected anal sex with someone of the opposite HIV-status to themselves, therefore risking HIV transmission or being exposed to HIV.
Where there are laws that criminalise same-sex sexual relations, governments are unlikely to promote any sort of HIV interventions aimed at men who have sex with men. As a result, men who have sex with men living in these countries are unaware of their risk of HIV, can be turned away from HIV services, are fearful of accessing HIV testing, and find it difficult to get hold of condoms and lubricants.
They are also unlikely to participate in research or prevention initiatives:
“…certain states would rather publicise their diplomatic distaste for atypical bodies, genders and sexualities instead of endorsing the protection of human rights and wellbeing of everyone.” – Gloria Carega & Azusa Yamashita
Stigma, discrimination and violence
A huge proportion of men who have sex with men worldwide have reported experiencing violence due to their sexual orientation. This is especially evident in machismo cultures, and patriarchal societies such as those in Latin America.
In some areas, it is public officials or even healthcare workers that are committing these offences. The fear of being identified as homosexual deters many men from accessing these services, avoiding healthcare check-ups and treatment in order to keep their orientation secret.
Lack of research
Although some statistics give an indication of the impact that HIV is having on men who have sex with men, data is still extremely scarce in many countries. This is largely due to the fact that men who have sex with men often have no separate social identity, and are simply counted as part of the general population.
It is also due to the reluctance of many governments to acknowledge men who have sex with men, and monitor this group. As a result, data about HIV among men who have sex with men is sparse, especially in regions like Eastern Europe and Central Asia. This reflects the punitive laws that criminalise same-sex behaviour in the region, and an unwillingness of governments to accept that there is a disproportionate epidemic emerging among this population. Seventy-three countries failed to report on HIV prevalence among men who have sex with men in 2013.
It has been suggested that in settings where MSM are a particularly stigmatised group, collaborations between the government and NGOs are the most effective way to reach this population.
“The frightening truth is that, in many parts of the world, we simply do not know how bad the epidemics among MSM groups may be… transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts.” – Dr. Chris Beyrer, Director of the Johns Hopkins Fogarty AIDS International Training and Research Program
Lack of funding
Apart from a handful of countries such as Brazil and Cuba, the majority of funding for HIV services targeted at men who have sex with men comes from international sources rather than domestic funding. In 2013, only 11% was domestically sourced worldwide.
Between 2005 and 2013, 38 countries did not report on their budget for men who have sex with men programming at all, suggesting no money was allocated for this key population. In sub-Saharan Africa, 30 of the 45 countries reporting in 2013 reported no spending on men who have sex with men programming.
Even in countries where the rights of men who have sex with men are legally respected, there is generally a greater need for more funding from donors and governments, as the amount of money put towards campaigns is often disproportionate to the scale of the problem.
The way forward
The evidence shows that providing HIV and AIDS services to those who are most at risk can be hugely beneficial to a whole country’s approach to HIV and AIDS. Governments and international donors must therefore cease to neglect the HIV epidemic among men who have sex men, and acknowledge the situation.
Not only is funding needed to provide HIV prevention, testing and treatment for men who have sex with men, but it’s also needed to generate research and data to inform effective programming. Without allocated funding for research and programme delivery, high HIV prevalence among men who have sex with men will remain.
Stigma and cultural opposition to same-sex relations are often largely to blame for rising epidemics. Until these issues are addressed, it will be difficult to reduce HIV infection levels among men who have sex with men. National and community level leadership is required worldwide to end stigma and discrimination of homosexuality