HIV epidemic among men who have sex with men: The Lancet Series

Gay, bisexual and other men who have sex with men are among those most as risk of HIV infection due to a combination of biological and social factors.

Gay, bisexual and other men who have sex with men are among those most as risk of HIV infection due to a combination of biological and social factors.

At the recent International Congress on AIDS in Asia and the Pacific (ICAAP) in Thailand, ‘The Lancet MSM and HIV Series’ symposium looked at why HIV prevention and treatment programmes for this group are not working as well as they should.

One of the issues is how the HIV epidemic among men who have sex with men is fundamentally different from other at risk groups and can lead to a more rapid HIV infection rate.

More effective prevention needed

The symposium highlighted that new and more effective HIV prevention programmes for men who have sex with men must reduce infectiousness through markedly expanding testing and treatment of HIV positive men, and reduce risk of acquisition among negative men through the use of pre-exposure prophylaxis (PrEP), the development of a rectal microbicide, and increased access to condoms and condom-compatible lubricant.

But the problem of stigma, discrimination and homophobia also needs to be addressed at both a societal and health care level, as this continues to limit access and uptake to essential services from testing to treatment, and from condoms to PrEP.

Chris Beyrer, president elect of the International AIDS Society and a professor at the Johns Hopkins School of Public Health, said: “The challenge facing the Asia-Pacific region is how to better respond to these epidemics. As in the past, and in other settings where vigorous responses are under way, this will only happen with the strong leadership, engagement and support of the affected community.”

Treating the whole man

Kenneth H. Mayer, medical research director of The Fenway Institute in Boston, went on to discuss “the whole man,” or comprehensive care to men who have sex with men, not just HIV concerns.  “Our thesis is that these are not vectors of transmission but people, and prevention will only work when people are respected and get comprehensive care,” said Dr Mayer. “Verbal and physical abuse can lead to internalised homophobia and depression, with a resulting potential for health problems. Health is not just an absence of disease, but also safe and pleasurable experiences.”

Patrick Sullivan, associate professor of epidemiology at Emory University School of
Public Health in Atlanta, said: “Current efforts have failed and we must do more. We know with the HIV prevention technology we have today that we can do more and help curb the epidemic.”

Australian academic and activist Dennis Altman highlighted that homophobia is the product of deeply ingrained views on gender roles, religion and national identity, and must be addressed at a systemic and structural level. According to Altman, legal equality is important, but also needs to be supported by real efforts to build acceptance of human diversity.

HIV community in Asia Pacific

The Asia-Pacific region has a strong and growing community engaging in issues around HIV and the health and rights of lesbian, gay, bisexual and transgender people more broadly.  But greater community involvement and donor support with current prevention and treatment approaches may not be enough.

New and more potent prevention technologies and approaches, including innovations in testing and tailoring of pre-exposure prophylaxis and of enhanced antiretroviral treatment approaches for men who have sex with men  who are already living with HIV, are likely to be key.

To make these services available, and to adapt them to this very large and diverse region, a new coalition may be necessary. Communities and scientists, implementers and policy leaders are going to have to work together and mobilise to bring innovation, greater engagement with young men in need, and new approaches to this next wave of the HIV epidemic.

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