At first glance, the latest global statistics on HIV are encouraging. According to UNAIDS, more than 21 million people are currently receiving antiretroviral therapy for HIV, the most effective treatment available. And the number of AIDS-related deaths is now fewer than one million per year — the lowest it’s been since the start of the 21st century.
Moreover, many countries around the world have committed to achieving “90-90-90” targets by 2020. That means setting the goal for 90 percent of HIV-positive people to know their status, 90 percent of people who know their status to receive treatment, and 90 percent of people receiving treatment to have an undetectable viral load.
But despite these promising developments, the rate of new HIV diagnoses is still rising among certain populations. This is particularly true for men who have sex with men (MSM), whose risk of contracting HIV is a staggering 27 times higher than other demographics.
It’s important to ask why MSM still face a much higher risk of HIV diagnosis, compared to other groups. Why, after so much time and progress, is this still the case? And, even more important, what can be done to protect the men most at risk?
While the risk of HIV infection is higher for MSM all over the world, the rate of new cases varies by region. UNAIDS gathered data and released an approximate global breakdown of new HIV diagnoses for 2017. According to this research, new HIV cases among MSM represent about:
- 57 percent of all new cases in North America, central Europe, and western Europe
- 41 percent of all new cases in Latin America
- 25 percent of all new cases in Asia, the Pacific, and the Caribbean
- 20 percent of all new cases in eastern Europe, central Asia, the Middle East, and North Africa
- 12 percent of all new cases in western and central Africa
Though there’s some regional variation, this isn’t an isolated trend. In most parts of the world, MSM face greater risk of HIV diagnosis compared to other groups.
Regional and universal challenges
Certain world regions have their own unique obstacles when it comes to preventing new HIV transmissions.
For example, in many countries — and especially in Africa and the Middle East — sex between men is criminalized. This pushes MSM to hide their sexual practices and to avoid seeking medical advice about HIV and other sexually transmitted diseases. It may also make it more challenging for healthcare providers and advocacy groups to offer sexual health information to MSM on how they can reduce the risk of HIV transmission.
All around the world — even in countries where same-sex practices, relationships, and marriages are legal — discrimination and homophobia persist. In varying degrees, this can impact MSM’s ability and willingness to access high-quality health services and information. The stigma that can accompany an HIV diagnosis also has an impact.
Availability of HIV testing varies around the world. Moreover, if MSM fear healthcare providers’ potential judgement, they may be less likely to get tested.
When people don’t get tested for HIV, they can’t find out if they have the virus. In turn, they won’t access treatment and antiretroviral therapy. They’re also more likely to transmit the virus to others.
Based on data from the Centers for Disease Control and Prevention (CDC), about 1 in 6 MSM in the United States who have HIV are unaware that they’re living with the virus. In some countries, the situation is worse. For example, in Kenya, Malawi, and South Africa, about one in three MSM with HIV don’t know they have it.
Certain biological factors can also put MSM at greater risk of HIV. Most MSM contract the virus from having anal sex without a condom. Condom-less anal sex has a higher risk of HIV transmission than some other sexual practices, such as oral sex.
Condoms help prevent HIV transmission, but rates of condom use among MSM vary worldwide. Lack of sex education, lack of access to condoms, and cultural norms around condoms are key issues that impact rates of use. In countries where condom use is low, MSM are at greater risk of contacting other sexually transmitted diseases, including syphilis, gonorrhea, and chlamydia — in addition to HIV.
Antiretroviral treatments also significantly reduce the risk of HIV transmission. These include pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medications. Even with exposure to the virus, such as through condom-less sex, PrEP and PEP are highly effective at preventing transmission. But around the world, the people most at risk for HIV may have difficulty obtaining these medications, whether due to lack of access or lack of information.
Overcoming these challenges may seem daunting, but it’s possible. Around the world, evidence is growing that certain approaches can make a huge difference when it comes to reducing the rate of new HIV diagnoses.
One of the most important steps towards reducing new cases in MSM is for countries to deliver antiretroviral therapies like PrEP on a large scale. Widespread PrEP programs are underway in a number of countries, including Australia, Brazil, Kenya, South Africa, United States, and Zimbabwe.
So far, the results have been promising. For example, in one region of Australia, the rapid introduction of PrEP was linked to a 35 percent decline in new HIV diagnoses. When PReP is made widely available, advertising campaigns and local initiatives are key to educating the public about the medication’s availability and effectiveness.
A shift towards community-based care is another important strategy for reducing new HIV cases. Outreach programs staffed with community healthcare workers can increase the likelihood that people with HIV will stick to their treatment plan.
Technology also offers new solutions. In China, a smartphone dating app called Blued has developed a system to connect its 40 million users with the nearest HIV testing site. This makes it easy for people to book an appointment. Data from 2016 suggests that clinics promoted in the app saw a 78 percent increase in the number of people tested.
De-criminalizing same-sex practices and relationships, while also addressing stigma and discrimination, makes a big difference. UNAIDS notes this encourages people with HIV to enroll in healthcare programs and stick with a treatment plan.
Finally, UNAIDS reports that it’s crucial for governments to offer affordable healthcare and eliminate health service user fees. This not only makes antiretroviral therapy more accessible, but also reduces the financial burdens associated with HIV.
The takeaway: Looking at the big picture
The rate of new HIV infections among men who have sex with men has risen worldwide, but the goal of achieving 90-90-90 targets by 2020 isn’t forgotten. To get there — or at least to get closer — collaboration between individual communities and national healthcare systems is imperative. HIV testing and antiretroviral therapy need to be accessible to the people most at risk of the virus.
Political, community, and business leaders around the world need to step up and work toward the financial investments and policy changes needed to ensure that progress happens. To stop the threat of HIV and AIDS for MSM, and all people, we need to rally together — not just locally, but on the global level, too.