HIV incidence rates are not decreasing for gay and bisexual men living in Africa

A recent large review suggests that while testing and knowledge of status may be improving, there is no progress in terms of viral suppression and prevalence of HIV for gay and bisexual men in Africa. Overall the HIV incidence in Africa is falling but this is not being replicated for gay and bisexual men, so these inequalities need to be addressed if the UNAIDS 95-95-95 targets are to be met for 2025. This systematic review from James Stannah and colleagues, published in Lancet HIV, evaluated HIV trends over almost two decades. The criminalisation of gay relationships in 32 African countries and stigma are likely to be barriers to HIV prevention for this group.

This systematic review used data from 152 studies, spanning 31 African countries, published from 2005 to 2023. Trends over this time were analysed for the testing, knowledge of status, treatment, incidence, and viral suppression rates of HIV in gay and bisexual men. The legal status of gay relationships in each country was also recorded. It was assumed that the number of gay and bisexual men was proportional in each country when calculating the percentages of these men that had been tested, diagnosed and treated for HIV. The figures for gay and bisexual men were compared to the overall estimates for all men living in these regions. Of note, there may also have been some transgender women included in these studies because of the definitions used to recruit participants.

Most of the studies were conducted between 2011 and 2020 (71%). Overall, 34% were done in western Africa, 33% in eastern Africa and 26% in southern Africa, leaving only a very small number of studies in northern and central Africa. In 100 of the studies which were conducted from 23 different countries, gay relationships were illegal.

The proportion of gay and bisexual men who had tested for HIV in the previous 12 months increased from 50% in 2010 to 82% in 2020. The number of these men who had ever tested also increased from 64% to 73% in the same period, with eastern African countries like Kenya and Tanzania showing particularly large increases. Knowledge of HIV status among gay and bisexual men living with HIV increased from 19% in 2010 to 51% in 2020. Current use of ART amongst men who have HIV increased from 14% in 2010 to 73% in 2020. Looking only at those who are aware of their HIV status, the increase is from 22% to 89%. Some evidence also suggested that the estimates for those who had ever done a HIV test, knowledge of status, new cases of HIV and current ART use were all lower for those living in places where gay relationships were illegal compared to where gay relationships were not criminalised. However, the estimates for these values were very wide ranging and not conclusive.

Viral suppression rates in 2020 were estimated at 69% of all gay and bisexual men living with HIV in Africa, 75% amongst men aware of their HIV status and 91% of those using HIV medication. Although some of the data suggests an increase in viral suppression over time, there was not strong enough evidence to prove this.

Most concerning is that in 2020 there were 6.9 new HIV cases per 100 men per year, with no conclusive evidence that this had significantly declined since 2006. When compared to the UNAIDS estimates in the general population of men in 2020, gay and bisexual men had an HIV incidence 27 times higher in eastern and southern Africa and 199 times higher in central and western Africa.

These studies show an improvement in testing and treatment, but no evidence to suggest a decrease in HIV incidence or viral suppression in this group, even though incidence is declining in the general population. The authors suggest that this may be due to a combination of criminalisation of gay relationships, difficulty accessing pre-exposure prophylaxis and financial constraints in these countries. The fear of public identification as a gay or bisexual man and the associated stigma and discrimination could be preventing men from accessing HIV services. This makes it important to integrate these men into general services but also ensure these service providers have the education and resources to help this specific population of men. The introduction of long-acting ART could also be crucial for getting those who are aware of their status onto effective and convenient treatment for them. Further studies are needed to make more definitive conclusions around engagement with HIV care, ART use and viral suppression.

As the authors concluded: “Better combination interventions tailored to the primary HIV prevention needs of MSM that address the social, structural, and behavioural factors that exacerbate their vulnerabilities to HIV will probably be important to increase access to ART and viral suppression and, ultimately, reduce disparities in HIV incidence.”