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Many MSM in Africa are missing out on treatment

Despite improvements in HIV testing among men who have sex with men (MSM) in Africa, many are missing out on HIV treatment. This is the finding of research, led by Imperial College London, which analysed data from 75 independent studies involving 44,993 MSM across 28 African countries, between 2004 and 2018.

The team found that levels of HIV testing and HIV status awareness among MSM in Africa were lower in countries with more severe anti-LGBT legislation. For example, a larger proportion of MSM had received an HIV test where there was more protective and progressive legislation, and fewer or no LGBT-related arrests, the analysis revealed.

The study, the first large meta-analysis of HIV testing and treatment among MSM in Africa, revealed that since 2011, around half of MSM in Africa had taken an HIV test in the last year (before 2011, only a third had done so).

This was greater than the proportion of men tested in the general population in Africa, yet MSM with HIV had significantly lower levels of treatment.

The study found only 19% of MSM with HIV were aware of their status – knew they had HIV. Among MSM living with HIV, only 24% were taking anti-retroviral therapy (ART). This therapy is the gold-standard for HIV treatment and reduces the amount of virus in the blood to undetectable levels, prolonging the life of people with HIV, and preventing subsequent sexual transmission to others.

By comparison, a different study from 2018 in six European and central Asian countries found 83% of MSM with HIV were aware of their status, and 70% were on ART. The team behind the current study also found levels of treatment among MSM were about 2.5 times lower than among men in the general population in Africa.

The team warn that if the situation remains unchanged, the UNAIDS targets of 90-90-90 by 2020 will not be achieved among MSM in Africa. These global targets aim for 90% of people living with HIV to be aware of their status, 90% of people aware of their status to be on ART, and 90% of people on ART achieving viral suppression by 2020, in order to control the HIV epidemic.

The researchers also found that few studies on awareness of HIV status, and particularly on treatment, have been conducted among MSM in Africa, especially in northern and central Africa. The team highlight the need for more studies to be conducted in this region to have a better picture of the situation among MSM throughout Africa.

The research was funded by the UKRI’s Medical Research Council, Department for International Development, and the US National Institutes of Health through the HIV Prevention Trials Network.

The scientists say many factors could account for the low proportion of MSM who undergo HIV testing and take ART. These include access to healthcare services and support, which may be more difficult in countries with more severe anti-LGBT legislation or where stigma against same sex relations is prevalent.

A statistically significant association was found between the proportion of MSM who seek HIV testing or know their status, and the severity of their country’s anti-LGBT legislation. Despite the small number of studies reporting on stigma, they found some evidence that stigma influenced HIV testing among MSM in Africa.

Professor Marie-Claude Boily, lead author from Imperial’s School of Public Health, said: “These results are important because MSM in Africa have not received sufficient national and global attention, yet are disproportionately affected by HIV. This study, the first large-scale analysis of HIV testing and treatment among MSM in Africa, suggests three in four MSM living with HIV in Africa may not be on ART, meaning a large fraction will unnecessarily die of Aids – and can pass on the virus to their partners. To reduce the burden of HIV among the MSM community and globally, we need to reach those groups of people who are most likely to acquire and transmit the virus.”

Dr Kate Mitchell, also from the School of Public Health and who co-led the study added: “There are many possible reasons why MSM in Africa may have low levels of testing and treatment, but this research shows two potential factors are anti-LGBT legislation and stigma, which is consistent with previous findings.”

James Stannah, first author of the study from the Medical Research Council Centre for Global Infectious Disease Analysis, at Imperial, explained the research supports previous evidence from other studies examining the effect of anti-LGBT laws and stigma on rates of HIV testing and treatment: “Globally, MSM are about 28 times more likely to be living with HIV than men in the general population. This inequality is particularly apparent in sub-Saharan Africa where almost two-thirds of countries still criminalise same-sex relations between men, many with long prison sentences and some with the death penalty. In an environment in which stigma and human rights violations linked to hostile legislation (including denial of healthcare and even discrimination from healthcare workers) have been shown to limit access to HIV-related services for MSM, more needs to be done."

The team says further research is now needed to assess the situation in a larger number of African countries, and to establish whether changes to legislation and reducing this stigma would increase the number of MSM in Africa who seek testing, and can then access treatment for HIV.

Dr Elizabeth Dale, joint first author from department of infectious disease epidemiology at Imperial, said: “More work is now needed to establish the effect of repealing anti-LGBT legislation on access to HIV services for MSM. Although there have been more studies in this area over time, we still urgently need research on MSM in Africa and their engagement with HIV services – particularly in Northern and Central Africa, where data is scarce. It is important to regularly monitor HIV testing and treatment among MSM in all African countries, and to monitor progress toward achieving UNAIDS 90-90-90 and identify key prevention gaps.”

In a linked Comment article, Dr Jean Joel Bigna of the Centre Pasteur of Cameroon, highlighted that this meta-analysis provides important updates on the current situation regarding the HIV care cascade among MSM in Africa, and indicates areas where it is urgent for governments in Africa to act and provide care, support, and preventive services for this stigmatised and discriminated vulnerable population.

Abstract 1

Background: HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma.
Methods: We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation.

Findings: Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1–72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4–57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the least severe legislation (57·4% vs 71·6%, p=0·0056; 35·5% vs 49·3%, p=0·010; 6·7% vs 22·0%, p=0·0050). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5–25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5–33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6–71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4–85·5; four estimates), but only 24·7% (18·8–31·2; four estimates) among all MSM living with HIV.
Interpretation: Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90–90–90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM.
Funding: US National Institutes of Health, UK Medical Research Council.

James Stannah, Elizabeth Dale, Jocelyn Elmes, Roisin Staunton, Chris Beyrer, Kate M Mitchell, Marie-Claude Boily

Abstract 2
Objectives: The aim of the study was to measure and compare national continuum of HIV care estimates in Europe and Central Asia in three key subpopulations: men who have sex with men (MSM), people who inject drugs (PWID) and migrants.
Methods: Responses to a 2016 European Centre for Disease Prevention and Control (ECDC) survey of 55 European and Central Asian countries were used to describe continuums of HIV care for the subpopulations. Data were analysed using three frameworks: Joint United Nations Programme on HIV/AIDS (UNAIDS) 90‐90‐90 targets; breakpoint analysis identifying reductions between adjacent continuum stages; quadrant analysis categorizing countries using 90% cut‐offs for continuum stages.

Results: Overall, 29 of 48 countries reported national data for all HIV continuum stages (numbers living with HIV, diagnosed, receiving treatment and virally suppressed). Six countries reported all stages for MSM, seven for PWID and two for migrants. Thirty‐one countries did not report data for MSM (34 for PWID and 41 for migrants). In countries that provided key‐population data, overall, 63%, 40% and 41% of MSM, PWID and migrants living with HIV were virally suppressed, respectively (compared with 68%, 65% and 68% nationally, for countries reporting key‐population data). Variation was observed between countries, with higher outcomes in subpopulations in Western Europe compared with Eastern Europe and Central Asia.
Conclusions: Few reporting countries can produce the continuum of HIV care for the three key populations. Where data are available, differences exist in outcomes between the general and key populations. While MSM broadly mirror national outcomes (in the West), PWID and migrants experience poorer treatment and viral suppression. Countries must develop continuum measures for key populations to identify and address inequalities.

AE Brown, K Attawell, D Hales, BD Rice, A Pharris, V Supervie, D Van Beckhoven, VC Delpech, M An der Heiden, U Marcus, M Maly, T Noori

[link url="http://www.imperial.ac.uk/news/193290/unaids-hiv-targets-will-missed-among/"]Imperial University London material[/link]

[link url="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30239-5/fulltext"]The Lancet HIV abstract[/link]

[link url="https://onlinelibrary.wiley.com/doi/abs/10.1111/hiv.12603"]HIV Medicine abstract[/link]

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