Urgent need to address "resurgent" gay global epidemic, says English public health chief

There is an increasing and potentially catastrophic HIV and sexual health epidemic in gay men and men who have sex with men (MSM) in every part of the world, Professor Kevin Fenton, the National Director of Health and Wellbeing at Public Health England, told the BHIVA autumn conference last week.

Despite having an increasing number of tools to prevent HIV, Professor Fenton added, HIV prevalence in MSM is increasing almost everywhere and incidence (the proportion who acquire HIV every year) is stubbornly refusing to change.

Professor Fenton said that optimising HIV testing programmes for MSM, particularly in countries where they faced criminalisation and discrimination, was key to controlling the epidemic, but that this would be a “challenge”.

HIV in gay men and MSM globally

Gay men everywhere have higher rates of HIV than in the general population, Fenton said. It is estimated that the HIV rate in MSM is eight times that of the general population in low-income countries and 23 times the general-population rate in high-income countries. The most reliable prevalence figures suggest that, regionally, Latin America and the Caribbean have especially high rates, but in no country of the world is HIV prevalence lower in MSM than in the population as a whole. Even in South Africa, the country with more people living with HIV than any other, HIV is twice as common in MSM as it is in other people.

In the developed world, the US has, by some way, the highest rate of HIV new diagnoses in MSM, though the UK has possibly the highest current rate in Europe. However, in terms of the rate of increase of new diagnoses, it is central-European countries such as Poland, the Czech Republic and Hungary, historically with very low prevalence, that are seeing the fastest-growing European epidemics in MSM.

In the lower-income world, reliable estimates of incidence are harder to come by, but over the last few years studies have found huge increases in HIV diagnoses in MSM in countries ranging from Thailand and China through Kenya to Nicaragua and Peru. The highest-ever annual HIV incidence recorded in a study comes from a group of MSM in Kenya, where a quarter of those originally HIV negative had HIV a year later. Unfortunately, African countries – and some in other areas of the world – initially denying they had MSM at all or any HIV problem in them, are now responding to the realisation that many people with HIV are MSM by introducing repressive measures such as increased criminalisation.

HIV was especially high, Fenton said, partly for biological reasons. It is now estimated that anal sex is 18 times better at transmitting HIV than vaginal sex. The chance of HIV being caught from having receptive anal sex once with a partner with a detectable HIV viral load is about 1.4% or one in 71 encounters; but because people have sex together more than once, the per-partner likelihood of catching HIV from a sero-different partner is, in gay men, about 40%.

Another factor in gay men’s higher HIV prevalence, Fenton added, was that because gay men have more partners and higher changeover rates, their sexual networks are more closely connected: 25% of gay men diagnosed with HIV were members of a cluster that had HIV viruses that were genetically identical, suggesting rapid transmission within the network, compared with 5% of heterosexual people.

Gay men do not just have more HIV for biological reasons, however, noted Fenton. The rates of smoking (at 27 to 66%, according to area), recreational drug use, lifetime depression (about 40%) and lifetime severe anxiety (at 20%) are all roughly double in gay men what they are in the general population. Underpinning these are higher rates of traumatic experience such as child sexual abuse (CSA) and intimate partner violence (IPV).

In several studies that looked at rates of depression, drug use, CSA and IPV in gay men, and related them to HIV prevalence and high risk sex, gay men with three or four of these conditions were twice as likely to have HIV and three times as likely to have had recent high-risk sex than men with none of them.

Socioeconomic disadvantage and racism also magnified the effects of HIV in MSM: this was one of the reasons why black gay men in the US are three times more likely to have HIV than white gay men.

Preventing HIV in gay men and MSM

How can we start to reduce the burden of HIV in gay men? Fenton commented that survey after survey showed that MSM, especially in parts of the world where they are criminalised and/or especially stigmatised, were reluctant to ‘come out’ to healthcare providers; often justifiably so, as there are many cases of their being refused HIV care and treatment if they do.

He called for healthcare workers to have training in the diversity of MSM and their health issues; culturally competent care is a basic human right, he added, especially as healthcare workers may be able to help MSM in their coming-out process because of their unique social role.

We have more HIV prevention options than we used to, and others based on antiretroviral therapy – such as pre-exposure prophylaxis (PrEP) – were in development, he said. HIV testing was now not just a gateway to treatment if MSM tested positive but could also be a gateway to a more tailored approach, and access to, behavioural and biomedical interventions for HIV. HIV testing frequency needed to increase in gay men, and options such as testing in routine care, at home and within social networks needed to be considered.

Gay men also needed to be helped to develop communication skills and more respectful attitudes towards their own health and towards other MSM. “We need to increase healthy, responsible and respectful sexual behaviours and relationships,” Fenton said, and to look at ways to help gay men have better sex with less harm.

Health workers needed training to provide “supportive, non-judgmental care”, he added, and the “sometimes systematic” exclusion of MSM from HIV prevention, services and research had to be combated.

Policies for enhancing HIV prevention in MSM did exist, Fenton concluded. As well as addressing the social and structural epidemic drivers, they included “ensuring effective and culturally competent combination prevention and treatment approaches”.