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.30
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.31
The tool, Implementing Comprehensive HIV and STI Programmes with Men Who Have Sex with Men [pdf], 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, which are well received by local men who have sex with men.32 Providing condoms and lubricant 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.33
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.34 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.35
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.36 Organisations staffed by men who have sex with men are also more credible and accessible to recipients.37
Case study: Peer training in the Philippines
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).38
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.39 The privacy of conducting an HIV test alone at home makes this an appealing option for many men who have sex with men. 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.40
Another study conducted in Australia found that HIV self-testing doubled frequency of testing among men who have sex with men at high risk of HIV, and quadrupled the frequency among non-recent testers, compared with standard care. It also showed that the availability of self-testing kits did not reduce the frequency of facility-based HIV testing.41
HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. Men who have sex with men should be educated about the use of self-testing kits, to heighten their confidence in using one as an alternative to testing 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.42
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. 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.43 Despite expanding evidence of its effectiveness in HIV prevention, access to PrEP remains limited. As of June 2017, some level of PrEP access had been approved in over 60 countries. This is double what it was in 2016 and is expected to continue to grow.44] 45
There are indications that, where individuals have been able to access it, PrEP has had considerable success in preventing new HIV infections among men who have sex with men, even in countries where it is not available within national healthcare systems. For example, sexual health clinics in London reported a 40% drop in the number of new HIV diagnoses among men who have sex with men in 2016. This has been attributed by several clinics to the purchasing of generic PrEP online, as the decline in new infections coincided with a rapid increase in the number of men buying PrEP online. I Want PrEP Now says that 2,000 men have been purchasing generic PrEP through its website, and services offered by several clinics to test for drug concentrations and adverse events related to PrEP have been well used. The decline in infections cannot with certainty be linked to PrEP, but the correlation of these factors is compelling.46
In order for PrEP to provide effective prevention it must be taken correctly and consistently.47 Men who have sex with men should be counselled and informed about the correct use of PrEP before it is offered. PrEP does not provide protection against STIs, and if not taken consistently is much less effective, so does not replace other prevention options like condoms.
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.48
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.49 The Adam’s Love organisation based in Thailand targets men who have sex with men and transgender women through an HIV educational website, eCounseling platforms and integrated social media networks. Since its launch in September 2011, Adam’s Love has had more than 2.8 million website visitors. Nearly 17,500 individuals received real-time counselling at Adam’s Love eCounseling platforms and were successfully linked to relevant clinical services, for example, HIV and sexually transmitted infection testing, treatment, and care and post-exposure prophylaxis (PEP).50
Case study: Online outreach in a hostile environment
A UNAIDS-supported project to address the vulnerabilities of gay men and other men who have sex with men in Egypt helped to achieve significant growth in reach and geographical coverage of related services from 2013. Innovations included outreach to men in slum areas through community-based organisations and awareness outreach and prevention services for the female sexual partners of gay men and other men who have sex with men.
Online outreach proved to be particularly effective for the project, as police action against this population had intensified, making street outreach more challenging. Following online outreach, meetings are arranged with participants to deliver condoms and lubricants; the project also facilitates access to good-quality, stigma-free health services and psychosocial and legal support.
In the period 2014– 2015 in Alexandria, the project reached around 1,000 people, distributed more than 3,100 condoms and packs of lubricant and facilitated 300 visits to project services. In Gharbya governorate, to which the project was expanded in 2015, nearly 300 people were reached and over 500 preventive packages were distributed.51