HIV in men who have sex with men 6: a call to action for comprehensive HIV services for men who have sex with men

Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
The Lancet (Impact Factor: 45.22). 07/2012; 380(9839):424-38. DOI: 10.1016/S0140-6736(12)61022-8
Source: PubMed


Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

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Available from: Kenneth Mayer, Dec 18, 2013
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    • "In other settings, higher personal wealth may contribute to delayed marriage and a higher number of lifetime sexual partners [42]. In addition, the criminalization of HIV transmission, sex work, homosexuality and drug use can block access to services in particular settings [43–45]. Interventions that attempt to address the material context may include social protection schemes, changing legislation and capacity building. "
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    ABSTRACT: Introduction Contemporary HIV-related theory and policy emphasize the importance of addressing the social drivers of HIV risk and vulnerability for a long-term response. Consequently, increasing attention is being given to social and structural interventions, and to social outcomes of HIV interventions. Appropriate indicators for social outcomes are needed in order to institutionalize the commitment to addressing social outcomes. This paper critically assesses the current state of social indicators within international HIV/AIDS monitoring and evaluation frameworks. Methods We analyzed the indicator frameworks of six international organizations involved in efforts to improve and synchronize the monitoring and evaluation of the HIV/AIDS response. Our analysis classifies the 328 unique indicators according to what they measure and assesses the degree to which they offer comprehensive measurement across three dimensions: domains of the social context, levels of change and organizational capacity. Results and discussion The majority of indicators focus on individual-level (clinical and behavioural) interventions and outcomes, neglecting structural interventions, community interventions and social outcomes (e.g. stigma reduction; community capacity building; policy-maker sensitization). The main tool used to address social aspects of HIV/AIDS is the disaggregation of data by social group. This raises three main limitations. Indicator frameworks do not provide comprehensive coverage of the diverse social drivers of the epidemic, particularly neglecting criminalization, stigma, discrimination and gender norms. There is a dearth of indicators for evaluating the social impacts of HIV interventions. Indicators of organizational capacity focus on capacity to effectively deliver and manage clinical services, neglecting capacity to respond appropriately and sustainably to complex social contexts. Conclusions Current indicator frameworks cannot adequately assess the social outcomes of HIV interventions. This limits knowledge about social drivers and inhibits the institutionalization of social approaches within the HIV/AIDS response. We conclude that indicator frameworks should expand to offer a more comprehensive range of social indicators for monitoring and evaluation and to include indicators of organizational capacity to tackle social drivers. While such expansion poses challenges for standardization and coordination, we argue that the complexity of interventions producing social outcomes necessitates capacity for flexibility and local tailoring in monitoring and evaluation.
    Journal of the International AIDS Society 08/2014; 17(1):19073. DOI:10.7448/IAS.17.1.19073 · 5.09 Impact Factor
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    • "HIV in men who have sex with men (MSM) influences the overall HIV epidemic in both low and high income countries, which is related to high per-act and per-partner transmission probability of HIV transmission in receptive anal sex [1-4]. According to the sentinel surveillance of the National AIDS Control Organization of India, HIV prevalence in MSM in 2008–2009 was estimated to be 7%, which is about 20 times higher than the overall national adult HIV prevalence rate [5]. "
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    ABSTRACT: Two rounds of integrated biological and behavioural assessment (IBBA) surveys were done among men who have sex with men (MSM) in Andhra Pradesh during 2006 and 2009. Avahan, the India AIDS initiative, funded by the Bill and Melinda Gates Foundation implemented HIV prevention interventions among MSM starting around the time of the first round of IBBA. Data on socio-demographic, sex behaviour characteristics and HIV status of MSM from the two IBBA rounds were used. Changes in the rates of consistent condom use over the past one month by MSM with various types of partners between the two rounds were assessed. Multivariate analysis was performed to assess associations between various factors and inconsistent condom use for sex with regular partners as well as HIV in MSM. A significant increase in consistent condom use by MSM was noted from 2006 to 2009 for paid male partners (19.5% to 93.8%), occasional male partners (13.2% to 86.2%), and paid female partners (25.9% to 94.2%). Consistent condom use with regular sex partners also increased but remained lower with regular male partner (75.8%) and very low with regular female partners (15.7%). MSM who used condoms inconsistently with their regular male partner were also more likely to use condoms inconsistently with their regular female partner. Multivariate analysis showed MSM who used condoms inconsistently with regular male partner had higher odds of HIV (odds ratio 1.8; 95% CI 1.2-2.7). MSM who received condoms from Avahan had the lowest odds (odds ratio 0.3; 95% CI 0.1-0.5) of inconsistent condom use with regular male partners. Condom use by MSM increased markedly after implementation of Avahan, though a causal association cannot be assessed with the available data. The relatively lower condom use with regular partners of MSM suggests that additional programme effort is needed to address this aspect specifically.
    BMC Public Health 01/2014; 14(1):64. DOI:10.1186/1471-2458-14-64 · 2.26 Impact Factor
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    • "Research has documented a strong correlation between criminalization of same-sex behaviour and lack of investment in services for MSM globally [21]. However, MSM have unique healthcare needs [22], and even in rights-constrained settings, comprehensive HIV services for MSM can and should be provided [23]. Our findings suggest the beginnings of political will among healthcare workers, key stakeholders at the government and local levels and the MSM community to provide these services. "
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    ABSTRACT: Introduction Despite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across settings, there has been little investigation of the experiences of MSM who are living with HIV in sub-Saharan Africa. Using the framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment needs of MSM who are living with HIV in Swaziland. Methods We conducted 40 in-depth interviews with 20 HIV-positive MSM, 16 interviews with key informants and three focus groups with MSM community members. Qualitative analysis was iterative and included debriefing sessions with a study staff, a stakeholders’ workshop and coding for key themes using Atlas.ti. Results The predominant theme was the significant and multiple forms of stigma and discrimination faced by MSM living with HIV in this setting due to both their sexual identity and HIV status. Dual stigma led to selective disclosure or lack of disclosure of both identities, and consequently a lack of social support for care-seeking and medication adherence. Perceived and experienced stigma from healthcare settings, particularly around sexual identity, also led to delayed care-seeking, travel to more distant clinics and missed opportunities for appropriate services. Participants described experiences of violence and lack of police protection as well as mental health challenges. Key informants, however, reflected on their duty to provide non-discriminatory services to all Swazis regardless of personal beliefs. Conclusions Intersectionality provides a framework for understanding the experiences of dual stigma and discrimination faced by MSM living with HIV in Swaziland and highlights how programmes and policies should consider the specific needs of this population when designing HIV prevention, care and treatment services. In Swaziland, the health sector should consider providing specialized training for healthcare providers, distributing condoms and lubricants and engaging MSM as peer outreach workers or expert clients. Interventions to reduce stigma, discrimination and violence against MSM and people living with HIV are also needed for both healthcare workers and the general population. Finally, research on experiences and needs of MSM living with HIV globally can help inform comprehensive HIV services for this population.
    Journal of the International AIDS Society 12/2013; 16(4(Suppl 3)). DOI:10.7448/IAS.16.4.18749 · 5.09 Impact Factor
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