The World Health Organization has issued comprehensive recommendations on the prevention and treatment of HIV and sexually transmitted infections among men who have sex with men and transgender people.
The guidance emphasises the very high vulnerability of men who have sex with men and transgender people to HIV infection, even in settings where the majority of HIV-infected people acquired HIV through sex between men and women.
"We cannot imagine fully reversing the global spread of HIV without addressing the specific HIV needs of these key populations," said Dr Gottfried Hirnschall, WHO's Director of HIV/AIDS Department. "We are issuing these guidelines to help countries and communities scale-up the services needed to reduce new infections and save lives."
"Men who have sex with men and transgender people everywhere face huge difficulties in accessing HIV services," said George Ayala, Executive Director of the Global Forum MSM & HIV (MSMGF), a key partner in producing the recommendations. "The guidelines both present evidence for effective prevention interventions for these populations and provide recommendations to help ensure that pervasive barriers like stigma and criminalisation no longer stand in the way of life-saving services."
Key recommendations
The number one recommendation in the guidance is the need for countries to decriminalise same-sex sexual activity, which is currently criminalised in more than 75 countries, and to create non-discriminatory and inclusive environments in which prevention, treatment and care can be delivered. Anti-discrimination laws which conform to international human rights standards need to be put in place in order to combat the enormous social stigma and violence attracted by same-sex desire and gender difference in many countries.
Non-discrimination in health care settings is also recommended as a necessity, in order to ensure that MSM and transgender people are able to access health services and receive appropriate care.
The guidelines also make a number of recommendations on the advice which should be given to MSM and on the prevention and treatment services that should be made available. The strength of the recommendations is based on a survey of the published evidence that has been assessed for its quality using a standardised WHO process for the evaluation of the evidence contributing to guideline recommendations.
Although research carried out for the guidelines development process by the Global Forum on MSM and HIV found no recognition of serosorting (choice of sexual partners of the same HIV status) among a global sample of MSM, the guidelines discuss serosorting as a possible prevention strategy
Consistent condom use is recommended in preference to serosorting for HIV-negative MSM, but in specific circumstances serosorting is recommended over not using condoms.
Male circumcision is not recommended as a preventive measure.
Offering HIV testing and counselling is strongly recommended. Offering community-based programmes for testing and counselling is recommended, although the low quality of the evidence supporting this recommendation is noted.
Individual behaviour change counselling is conditionally recommended subject to available human resources, as are community-level behavioural interventions.
Targeted internet-based information to support risk reduction is conditionally recommended, together with social marketing strategies to increase the uptake of HIV testing and counselling and other HIV services.
Sex venue-based outreach services are conditionally recommended, although the guidelines note the low quality of evidence and suggest that more research is needed in low and middle-income countries to determine the effect of these interventions on HIV or STI incidence.
Those with harmful alcohol or other substance use should have access to evidence-based brief psychosocial interventions involving assessment, specific feedback and advice, in line with current WHO guidance.
The guideline also emphasise the importance of providing access to needle and syringe exchange programmes, and provision of sterile injecting equipment and training in safe injecting behaviours for transgender people who are injecting substances for gender enhancement.
The guidelines emphasise the importance of syndromic management of symptomatic sexually transmitted infections in accordance with existing WHO guidance, and also conditionally recommend periodic testing for asymptomatic urethral and rectal gonorrhoea and Chlamydia, using nucleic acid testing.
Periodic serological screening for asymptomatic syphilis is strongly recommended, and the guidelines reiterate existing WHO guidance on the need to include MSM and transgender people in hepatitis B immunisation strategies.
The full guidelines document can be downloaded here.