Elsevier

The Lancet

Volume 380, Issue 9839, 28 July–3 August 2012, Pages 388-399
The Lancet

Series
Successes and challenges of HIV prevention in men who have sex with men

https://doi.org/10.1016/S0140-6736(12)60955-6Get rights and content

Summary

Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide. Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. Our review of HIV prevention strategies for MSM identified several important themes. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission. Biomedical prevention strategies reduce the incidence of HIV infection. Delivery of barrier and biomedical interventions with coordinated behavioural and structural strategies could optimise the effectiveness of prevention. Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries. Scale-up of HIV prevention programmes for MSM is difficult because of homophobia and bias, suboptimum access to HIV testing and care, and financial constraints.

Introduction

Men who have sex with men (MSM) have always had a key role in the global HIV epidemic.1 HIV epidemics in MSM are re-emerging in high-income countries2 and have been noted in many low-income and middle-income countries.3, 4 We review HIV prevention interventions for MSM, emphasise the importance of the development and assessment of combination prevention packages, and address challenges. The World Bank used the highest attainable standard of evidence (HASTE) system (which also includes data for implementation science) in its 2011 review5 of published work, whereas WHO used the grading of recommendations assessment, development and evaluation (GRADE) system.6 We combine these reviews and our own comprehensive review of work and suggest a conceptual framework for packaging of interventions and modelling of the potential effect of scale-up of HIV prevention interventions for MSM.

Key messages

  • Governmental, academic, and community strategies have been insufficient to curb the HIV epidemic in men who have sex with men (MSM).

  • HIV prevention is difficult for MSM because of the high biological risk associated with anal intercourse, high frequency and variety of sexual activity, little acknowledgment of male–male sex by governments and health-care providers, discrimination, few specific services for MSM, and syndemic challenges (eg, substance misuse).

  • In most parts of the world, restricted resources and legal barriers complicate the effective provision of HIV prevention services for MSM.

  • Resources are scarce for HIV prevention services in MSM and scale-up is problematic. Available interventions are insufficient, largely untested in most developing countries, and not sufficiently tailored to MSM.

  • Several behavioural interventions are somewhat efficacious in reduction of the frequency of unprotected anal intercourse in MSM, but none effectively decreases the incidence of new HIV infections. However, behavioural interventions have not been fully assessed in some environments, and they have a crucial role in combination with barrier and biomedical interventions.

  • Coordinated behavioural, biomedical, and structural interventions that incorporate efficacious strategies could substantially reduce the incidence of HIV infection in MSM.

  • Prevention efforts reach only a small proportion of MSM, and scalability should be considered when new interventions and packaging approaches are developed.

Section snippets

Prevention interventions

Early HIV prevention efforts focused on behaviour change and yielded many successes, but did not provide sufficient strategies to curb the epidemic. More recently, approaches have been inclusive of biomedical strategies. Treatment and behavioural and biomedical approaches are not at odds with one another, but rather have complementary roles in a broad, coordinated, and science-based approach to HIV prevention in MSM. Indeed, the strengths and opportunities associated with each strategy suggest

Behavioural interventions

Stand-alone behavioural interventions are not sufficient to reduce HIV transmission in MSM.7 Previously, behavioural interventions typically targeted sexual risks such as unprotected anal intercourse and having many sex partners, substance or alcohol use, and adherence to antiretrovirals. Such interventions seem to decrease the frequency of unprotected sex by about 27% compared with control populations exposed to few or no HIV prevention interventions, and by 17% compared with controls

Biomedical and barrier interventions

Biomedical and barrier approaches destroy HIV in the rectal or vaginal compartment, create a hostile environment (which can be pharmacological or immunological) that prevents local viral replication, or provide a barrier between the virus and susceptible cells. Evidence shows that condoms and pre-exposure treatment with antiretrovirals reduce the risk of HIV infection. The efficacy of other approaches—eg, postexposure treatment with antiretrovirals, HIV vaccines, use of antiretrovirals for

Condoms

Condoms are highly efficacious in HIV prevention. A Cochrane review22 showed that use of condoms reduced HIV transmission in HIV-discordant heterosexual couples by an estimated 85%. Investigators of the collaborative HIV seroincidence study23 suggested that for receptive anal intercourse, condom use reduced the per-contact risk of HIV infection by 78% compared with unprotected anal intercourse. Despite these findings, condom use by MSM is problematic. Issues include difficulty in negotiating

Antiretrovirals

Antiretroviral therapy can be given to HIV-negative people after a high-risk HIV exposure (so-called postexposure prophylaxis; appendix) or before potential high-risk activity (pre-exposure prophylaxis). The pre-exposure prophylaxis initiative (iPrEx) was a study31 designed to assess the safety and efficacy of pre-exposure prophylaxis with daily tenofovir and emtricitabine (Truvada) in MSM and transgender women. 2499 HIV-negative men and transgender women were followed up for a median of 1·2

Community interventions

At a community level, programmes to promote comprehensive HIV testing, linkage to care, and viral suppression through treatment with antiretrovirals are proposed by prevention scientists to lower the viral load and thereby decrease transmission of HIV. In San Francisco, where most HIV infections occur in MSM, early ecological analyses37 suggest that decreases in community viral load are associated with a fall in the incidence of HIV infection. However, the period of observation in San Francisco

Microbicides

When applied to the vaginal or rectal mucosae, microbicides prevent or substantially reduce the acquisition of HIV or other STIs.43 The results of the Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 study44 showed that a vaginal microbicide gel containing 1% weight/weight tenofovir reduced HIV acquisition in women by 39% compared with placebo.44 The same gel provided substantial protection against rectal challenge in non-human-primate studies,45 providing a rationale for

Vaccination

Two trials of HIV vaccine efficacy are of particular relevance to MSM. In the Step study51 (HVTN 502/Merck 023), the replication-incompetent adenovirus 5 vector might have increased the risk of HIV infection in uncircumcised MSM with pre-existing neutralising antibodies specific to the adenovirus. The results of the Thai RV144 trial52 showed a significant (31%) reduction in HIV acquisition in people given the vaccine compared with those given placebo.52 However, the heterosexual men in this

HIV testing

HIV testing underlies the effectiveness and implementation of nearly all other prevention approaches and is the gateway to the offering of services tailored to client needs. HIV testing itself is an intervention; meta-analytic evidence shows that most people who discover that they are HIV positive take steps to reduce the risk of transmission to others.55 Furthermore, many MSM are unaware of their HIV serostatus.56, 57 Accurate knowledge of serostatus is probably a key driver of whether

Diagnosis and treatment of STIs

Bacterial and viral STIs can increase the efficiency of HIV transmission.58, 59 Urethritis increases seminal viral load in HIV-positive MSM,60 and increased virus numbers in semen are associated with high transmission risk in heterosexual men.61 However, to show that syndromic treatment of STIs with antibiotics prevents HIV acquisition is difficult.62 High-quality evidence suggests that suppression of herpes simplex virus type 2 in MSM does not prevent HIV transmission.63, 64 Incident STIs are

Combination prevention

Any single prevention modality is unlikely to provide complete protection from HIV infection.66 Combination of treatment interventions to produce a synergistic effect is not new,67 and multilevel HIV prevention has been advocated in a previous Lancet Series.7 Prevention packages are combinations of HIV prevention interventions, assembled to work together to optimise effectiveness. Several principles should guide the development and testing of such prevention packages. Prevention packages might

Modelling

To establish the potential effect of intervention packages at a population level, we used the stochastic, agent-based simulation model of HIV transmission that was developed for the Prevention Umbrella for MSM in the Americas Project, and used by Beyrer and colleagues (their appendix describes the modelling framework in detail).68 We used a more fully parameterised model to represent the MSM transmission network for four case studies of epidemic patterns: an MSM-focused epidemic in a developed

Scale-up

Even if trials of tailored intervention packages are successful, their scale-up and implementation are uncertain. Availability of basic HIV prevention services for MSM is poor, foreshadowing the challenges of implementation of further complicated and costly packages. However, a global model of successful implementation of multicomponent community health care has emerged in India, where Avahan—the Indian initiative of the Bill & Melinda Gates Foundation—provides behaviour change interventions

Coverage of interventions

To assess coverage of HIV prevention interventions for MSM, identify gaps in provision of core services, and plan resource needs, countries should first establish the coverage of basic prevention services. In many cases, these baseline assessments are not done, or are done inadequately. For example, an assessment of the 2008 UN General Assembly Special Sessions indicators81 showed that less than 50% of low-income and middle-income countries reported at least one key indicator of provision of

New technologies

New technologies offer new opportunities for interventions and to improve efficiency of scale-up for existing interventions. A meta-analysis by Noar and colleagues85 showed that, irrespective of the risk population, the efficacy of computer-delivered interventions might be similar to that of human-administered interventions. Technology-assisted interventions might assist with scale-up through provision of efficient ways to administer intervention content and periodic reminders for rescreening,

Challenging settings

Scarce resources, prevalent prejudice against MSM, criminalisation (of male–male sex, HIV transmission, or sex work), little recognition or nascent organisation of MSM communities, and an absence of cultural competency training for health-care providers can complicate effective HIV prevention programmes for MSM. Prisons are also a challenging setting (appendix). Although all countries struggle with these challenges, many countries in Africa and Asia have difficulties with several of these

Conclusion

The next steps in HIV prevention in MSM will be technically difficult and costly. Proof-of-concept studies of combination prevention approaches should be followed by large, multicentre prevention trials of promising packages. To achieve this aim, innovative study designs and new networks of research capacity will be needed, especially in low-income and middle-income countries.78 Furthermore, resources for scale-up and changes to laws and policies that frustrate the best practices of public

Search strategy and selection criteria

Between Oct 11, 2011, and Jan 9, 2012, we reviewed HIV prevention interventions for MSM published in English on PubMed, Embase, Scopus, PsycINFO, Social Sciences Citation Index, Science Citation Index Expanded, Conference Proceedings Citation Index–Science, and the Cumulative Index to Nursing and Allied Health Literature, and focused whenever possible on systematic reviews and meta-analyses (appendix). We also inventoried the results of meta-analyses of HIV prevention in MSM. We compiled 1871

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