Men who have sex with men (MSM), HIV and AIDS
- There are biological, behavioural and legal factors which put men who have sex with men 24 times more at risk of HIV compared with the general population.
- Many countries have made significant progress in recognising the rights of LGBTQ people, while in other countries punitive laws and homophobia create additional barriers for men who have sex with men from accessing HIV prevention, testing and treatment services.
- Globally, more funding is required to support targeted HIV prevention, testing and treatment programmes for men who have sex with men.
Explore this page to find out more about what factors put men who have sex with men at risk of HIV, HIV prevention programmes, HIV testing initiatives, using technology, access to antiretroviral treatment, barriers to prevention and the way forward for men who have sex with men.
Globally, men who have sex with men (sometimes referred to as MSM) are 24 times more likely to be living with HIV than the general population.1 New diagnoses among this group are increasing in some regions – with a 17% rise in Western and Central Europe and a rise of 8% in North America between 2010 and 2014.2
In 2015, men who have sex with men made up 12% of new HIV infections worldwide, and accounted for 54% of new HIV infections in Western Europe, 68% in North America and 30% in Latin America and the Caribbean.3 4 In Mauritania, nearly 45% of men who have sex with men are living with HIV.5
Some nations, have progressive attitudes and policies regarding homosexuality and the lesbian, gay, bisexual and transgender (LGBT) community. In Latin America, West Europe, Central Europe and North America, many countries have made significant progress in recognising the rights of LGBTQ people and allow marriage or civil unions between people of the same sex.6 7
However, the majority of Africa, along with the Middle East and Russia, continues to ignore and abuse the human rights of men who have sex with men.8 Punitive laws in various countries drive this population underground, elevating their risk of HIV and preventing them from accessing healthcare including HIV services.
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 sex within this group.9 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.10
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 has been found to be low (less than 55% across all regions in 2013). This means that many are living with an undiagnosed STI which may put them at higher risk of HIV.11
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.12
Having multiple sexual partners is more common among this community, and many men who have sex with men do not use condoms consistently. In about half of the countries that recently reported data, less than 60% of men who have sex with men had reported using a condom at last anal sex.13 Data on other sexually transmitted infections among gay men and other men who have sex with men are further evidence of inconsistent use of condoms.14 It has been suggested that one of the reasons for this, is that safer sex campaigns have lost traction among this group. In the United States, for example, the percentage of men reporting using a condom at last anal sex decreased from 41% in 2011 to 35% in 2014.15
Access to HIV testing services among this group is varied. In several European and North American cities men who have sex with men are approaching or have exceeded the 90-90-90 targets, with over 90% of men who have sex with men aware of their HIV status. Yet the HPTN trial in Kenya, Malawi and South Africa, found that only one in three positive men were aware of their status, and in Mozambique it was fewer than 10%.16 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.17
Not testing for HIV, means that many men who have sex with men are unaware of their HIV status and may be unaware of the need to take protective measures to prevent onwards transmission to others.
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, increasing the risk of HIV transmission.18
In the United Kingdom and the USA there is a growing trend for men who have sex with men to participate in group sex under the influence of psychoactive and performance enhancing drugs, most commonly known as ‘chemsex’ (but is sometimes referred to as party and play or PNP). The drugs of interest – namely GHB (gamma-hydoxybutyrate), methamphetamine and methedrone – are used to facilitate sexual sessions lasting many hours or even days with multiple partners. It was recently estimated that 3 in 10 gay men in the UK had engaged in chemsex in the last year.19
Healthcare professionals are particularly concerned with the high-risk behaviours that these drugs induce; a lack of physical inhibition and awareness often means a participant is exposed to multiple partners without protection or to shared drug taking equipment which increases the risk of HIV transmission. In cases where sexual activity is prolonged there is also a concern that participants living with HIV may forget to take ART medication, or that those who are HIV negative will miss the 72-hour window to be eligible for receiving post-exposure prophylaxis (PEP) after suspected exposure to HIV. 20
Men who have sex with men living with HIV often become HIV-positive while still young. Estimates suggest that 4.2% of young (under-25s) 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.21 One study carried out in Bangkok found HIV incidence was more than twice as high among men aged 18 to 21 years compared to men over 30 years of age.22
Young men who have sex with men often find it harder to access HIV services, due to age of consent laws or unsociable opening times. 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%).23
As of May 2016, 73 countries still criminalise same-sex conduct, affecting the rights of men who have sex with men and other members of the LGBT community. In 13 countries including Iran, Sudan, Saudi Arabia, Yemen and parts of Nigeria and Somalia, homosexuality is punishable by the death penalty.24 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 17 countries ‘homosexual propaganda’ is banned or ‘morality laws’ actively target public promotion or expression of same-sex and trans realities. Such laws have been introduced in recent years in countries including Russia, Lithuania and Nigeria.25 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.26
Russian-style propaganda laws are also being proposed in Ukraine, Belarus, Bulgaria, Latvia, Kazakhstan and Kyrgyzstan.27
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.28
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.29