Despite improvements in HIV testing among men who have sex with men (MSM) in Africa, they are missing out on HIV treatment.
This is the finding of research, published in The Lancet HIV, 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 study, the first large systematic review and 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 had significantly lower levels of treatment.
The study found only 19 per cent of MSM with HIV were aware of their status – i.e. knew they had an HIV infection.
Among MSM living with HIV, only 24 per cent 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, meaning it substantially prolongs the life of HIV infected individuals, and the virus can’t be transmitted.
The researchers behind this study 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 per cent of people living with HIV to be aware of their status, 90 per cent of people aware of their status to be on ART, and 90 per cent of people on ART achieving viral suppression by 2020, in order to control the HIV epidemic.
By comparison, a different study from 2018 in six European and central Asian countries found 83 per cent of MSM with HIV were aware of their status, and 70 per cent were on ART. The levels of treatment among MSM were about 2.5 times lower than among men in the general population in Africa.
The team at Imperial found that levels of HIV testing and HIV status awareness among MSM in Africa were lower in countries with more severe anti-LGBT legislation and found some evidence that stigma against MSM influenced HIV testing.
“Many factors could account for the low proportion of MSM who undergo HIV testing and take ART,” says James Stannah, the study’s first author who did the work while a research assistant at Imperial College London. “These include access to healthcare services and support, which may be more difficult in countries with more severe anti-LGBT legislation or stigma against same sex relations.”
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 that a large fraction will unnecessarily die of AIDS and that they 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 HIV.”
Dr Kate Mitchell, 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.”
Stannah, who is currently a doctoral student at McGill University in the Faculty of Medicine in the Department of Epidemiology, Biostatistics, and Occupational Health, explained that the research highlights the challenges faced by MSM in Africa in accessing HIV testing and treatment. “Globally, MSM are about 28 times more likely to be living with HIV than men in the general population – an inequality which is particularly apparent in sub-Saharan Africa. In an environment in which stigma and human rights violations linked to hostile legislation have been shown to limit access to HIV-related services for MSM, more needs to be done."
Dr Elizabeth Dale, joint first author from Imperial, said: “More work is now needed to assess the situation in more 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 HIV treatment. 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”
The research was funded by the UK Medical Research Council and Department for International Development, and the US National Institutes of Health through the HIV Prevention Trial Network.
HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis, by James Stannah, Elizabeth Dale, Jocelyn Elmes, Roisin Staunton, Chris Beyrer, Kate M Mitchell, Marie-Claude Boily was published in the journal The Lancet HIV:www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30239-5/fulltext
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