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The Global HIV Epidemic among Men Who Have Sex with Men in Low and Middle-Income Countries

Led by Drs. Chris Beyrer, Andrea Wirtz, Damian Walker, Frangiscos Sifakis, Benjamin Johns, and Stefan Baral 
Collaboration with the World Bank and Futures Institute

Just released! The CPHHR collaborative report with the World Bank, The Global HIV Epidemics among Men Who Have Sex With Men, has been released in time with the UN General Assembly's High Level Meeting on AIDS.  CPHHR_WB_GlobalHIVamongMSM_Cover_FNL2011.jpgRead more: Full report Summary Press Release Lancet Review

Background: HIV/AIDS first emerged among populations of gay men and other men who have sex with men (MSM ) in Western Europe, North America, and Australia, in the early 1980s.  This reality shaped early responses to the epidemic and has had lasting impacts on the stigma associated with HIV/AIDS.   More than a quarter-century later and in an increasingly broad range of countries, contexts and development levels, data are emerging which show that epidemics of HIV among MSM are no longer limited to the high-income countries in which they were initially described. Recent evidence from a wide range of sources suggests that men who have sex with men (MSM) are at marked risk for HIV infection in Low and Middle-Income Countries (LMIC) in Asia, Africa, Latin America and the Caribbean, and in Eastern Europe and Central Asia.  HIV prevalence rates have been consistently higher among MSM compared to general population estimates of reproductive age men virtually wherever MSM have been well studied, and HIV incidence data, while markedly scarcer, generally have supported high acquisition and transmission risks among MSM in multiple contexts, cultural settings, and across economic levels. 

Research among MSM in LMIC has been limited by the criminalization and social stigmatization of these behaviors, safety considerations for study participants, the hidden nature of these populations, and lack of targeted funding.  Because these men are so hidden, there is generally marked under-reporting of MSM behavior in population-based surveys, and there has been limited work on the kinds of surveillance necessary to characterize these men and the emerging epidemics affecting them. Most available data evaluating determinants of HIV risk among MSM are derived from high-income country samples. Available evidence from these countries suggests that structural risks—social, economic, political, or legal factors—are likely as important as individual-level risk factors in shaping HIV risks and HIV/AIDS treatment and care options for these men.  These same factors may have profound effects on how HIV epidemics in MSM effect wider populations.

MSM are markedly underserved and under-resourced populations in many settings.  There is limited coverage and access to HIV/AIDS prevention, treatment, and care services—with some estimates suggesting that fewer than 1 in 10 MSM worldwide have access to the most basic package of preventive interventions.  Stigma, discrimination, and criminalization limit these men’s access to what services are available.  Nevertheless there is considerable evidence that HIV preventive interventions, at individual, community, and population levels have been effective and need to be markedly expanded to control the global epidemic of HIV among MSM and to mitigate its impact.

To improve LMIC responses to HIV/AIDS it is essential that services expand for MSM and that exclusion from key emerging interventions, such as expanded VCT, earlier access to treatment, and treatment as prevention modalities be addressed.  This report seeks to inform these responses by posing, and attempting to answer, several key questions.  While a global response is called for, most country-specific epidemics among MSM have both common and unique features when compared to other LMICs.

Our work: In addition to conducting our population based studies (currently in several African Countries, Kazakhstan, Nepal, and Russia) we are conducting a global review in an effort to answer the following questions and determine the most efficient and effective ways to move forward to address the HIV epidemic among MSM in LMIC.

What fraction of the burden of HIV disease in selected countries that is attributable to gay, bisexual, and other MSM behaviors? How does this vary by scenario and across the representative states?

Where are we in 2010 in terms of coverage for prevention, treatment, and care for MSM in these selected countries?

What would constitute a minimum adaptable package of evidence-based and human rights affirming services for MSM prevention, treatment, and care?

What would it take in terms of resources, political will, and novel approaches, to reach acceptable coverage levels of MSM in the targeted countries with this essential minimum package of services? And how might resources be maximized to ensure acceptable coverage of MSM populations by the prevention and treatment packages?

To answer these and related questions we have a conducted a several-staged analysis of the global epidemics of HIV among MSM in LMIC.  First, we have reviewed the available data on MSM including taxonomies, HIV epidemiology, risk factors, and access to prevention, treatment, and care, in nine (9) selected countries, including Peru, Brazil, Thailand, India, Russia, Ukraine, Kenya, Senegal, and Malawi.  We conducted a global review of the epidemiologic literature and used these data to generate an algorithmic approach to characterizing HIV epidemics among MSM.  See our publications and presentations below for the most recent results.  Results from modeling and cost-analysis are expected in Fall 2010.

Current work funded by the World Bank, Global AIDS program

News:

World Bank report reviewed in the Lancet, by Tom Coates
"
Beyrer and his colleagues show us that MSM are everywhere in the world and disproportionately affected by the HIV epidemic. They highlight how MSM are underserved nearly everywhere and that the global response to HIV will stall without access to treatment and prevention services in the context of protection of fundamental human rights. The HIV global epidemic among MSM is only beginning to be addressed. Beyrer's book is a key part of the momentum that will continue to propel us in the right direction." Read more

The CPHHR's report for the World Bank, the Global HIV Epidemic among MSM, is listed among the MSM Global Forum's Top 10 Key Global Policy Developments Concerning MSM & HIV 

Publications:

Baral S, Adams D, Lebona J., Kaibe B., Letsie P, Tshehlo R. Wirtz AL, Beyrer, C.  A Rapid Assessment of Population Demographics, Sexual Practices, HIV Risk Status, and Human Rights Contexts among Men who have Sex with Men in Lesotho.  JIAS.  2011 July 4; 14:36.

Fay H, Baral S, Trapence G, Motimedi F, Umar E, et al. Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana. AIDS and Behavior, Dec 2010: 1-10.

Beyrer C, Baral SD, Walker D, Wirtz AL, Johns B, Sifakis F.The Expanding Epidemics of HIV Type 1 Among Men Who Have Sex With Men in Low- and Middle-IncomeCountries: Diversity and Consistency. Epidemiol Rev. 2010 Jun 23. [Epub ahead of print]

Beyrer C. Global prevention of HIV infection for neglected populations: men who have sex with men. Clinical Infectious Disease. 2010 May 15; 50 Suppl 3:S108-13.

Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Baral S: Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men (MSM). STI; April 2010.

Baral S, Trapence G, Motimedi F, Umar E, LIpinge S, Dausab F, Beyrer C. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One Mar 2009: 4(3).

Beyrer, C. Hidden yet happening: the epidemics of sexually transmitted infections and HIV among men who have sex with men in developing countries. STI 2008 Nov:84(6).

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:Results of a meta-analysis. PLoS Med 2007 Dec; 4(12):e339.

Presentations:

AIDS 2010 Conference: The Global HIV Epidemic among MSM
July 17, 2010
Opening Plenary of the MSMGF's Pre-Conference
Watch: Part 1  Part 2

AIDS 2010 Conference: Know Your Epidemic, Know Your Response: MSM and Their Needs in Low and Middle-income Countries
July 22, 2010
Panel discussion with Dr. Baral, Andy Seale, Joeal Nana, Nyambura Njoroge, Zoran Kis, and Shivananda Khan
Watch Listen Presentation

Bisexual concurrency in Southern Africa
July 27, 2010
BMJ Podcast interview with Dr. Baral
Listen

Dramatic Rise in HIV Infection Reported Among Men who have Sex with Men
August 8, 2008
Voice of America
Listen

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