Gay, bisexual, and other men who have sex with men (MSM) have been a core population affected by the HIV/AIDS epidemic since the syndrome we now know as AIDS was first identified in previously healthy homosexual men in the USA in 1981.1 It was soon clear that HIV had been circulating in human populations decades before this discovery, and through various routes of exposure. But the fact that HIV was first identified in gay men indelibly marked the global response, stigmatised those living with the virus, limited effective public health responses in some cases, and drove coercive and punitive ones in others.2 In the fourth decade of the HIV epidemic, that these men and their communities should continue to endure stigma, discrimination, and scarceness of access to HIV services3 and that homophobia should continue to potentiate the epidemic is unconscionable. This situation must change.
The newfound optimism in the HIV specialty, that early antiretroviral therapy is an effective preventive intervention strategy,4 and that new prevention methods such as the combination of tenofovir and emtricitabine (Truvada) chemoprophylaxis have efficacy for MSM,5 opens up real possibilities for the eventual achievement of control of HIV subepidemics in MSM.6 And HIV treatment advances, coupled with the provision of culturally competent care, provide pathways forward toward the realisation of the right to health.7 None of these goals can be achieved, however, if MSM continue to be denied health-care services. In too many settings in 2012, MSM still do not have access to the most basic of HIV services and technologies such as affordable and accessible condoms, appropriate lubricants, and safe HIV testing and counselling.6
In 2012, the global AIDS community is at a crossroads. Research advances suggest pathways to reach what US Secretary of State Hillary Clinton has called “an AIDS-free generation”.8 Many argue that we now have the means in hand to achieve this goal—unimaginable only a few years ago.9 And the unprecedented commitment of global resources to prevent HIV and treat AIDS, exemplified by the multibillion dollar commitments of the Global Fund to Fight AIDS, Malaria and Tuberculosis, the US PEPFAR Program, and various governments and private foundations, has saved millions of lives. But donor aid declined in 2011, as has general interest in HIV. We might not have the leadership and political support we need to achieve an “AIDS-free generation”.8
Key messages
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HIV epidemics in 2012 are severe and expanding in MSM globally, in both low-income and high-income country settings. Despite evidence of this disproportionate burden, HIV in men who have sex with men continues to be understudied, under-resourced, and inadequately addressed.
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The ongoing exclusion of MSM from health care, and from full social and political participation, must change. No population at risk for HIV infection can be excluded if we are to achieve control of AIDS worldwide.
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A modest global investment of US$134 million in the coming year could provide enough condoms and lubricant to set a course towards averting 25% of global HIV infections in MSM in the next 10 years.
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The high transmission efficiency for HIV in MSM suggests that prevention approaches that can reduce probabilities of per-act transmission will probably be needed to produce substantial reductions in new infections. These interventions include antiretroviral-based approaches. Reductions in cost of antiretroviral drugs for primary prevention and for treatment will be crucial to the cost-effectiveness and feasibility of antiretroviral-based approaches to HIV in MSM, especially in high-income countries.
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MSM are citizens of every country of the world—national governments must develop comprehensive programmes to provide care, support, and preventive services for these men.
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Mobilisation and engagement of MSM remains crucial in the AIDS response. In many countries, only MSM are willing to fight anti-gay stigma, demand adequate health services, and bear the risks implicated in providing services.
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Human rights are universal, and sexual orientation is not grounds for exclusion.
For MSM, even more challenging realities exist than for the rest of the population. As reported by Beyrer and colleagues,10 HIV infection rates in MSM have been increasing in many settings in the era of highly active antiretroviral therapy. A comprehensive review of the burden of HIV disease in MSM worldwide found that pooled HIV prevalence ranged from a low of 3·0% (95% CI 2·4–3·6) in the Middle East and north Africa to a high of 25·4% (21·4–29·5) of MSM in the Caribbean. Pooled HIV prevalence was fairly consistent across North, South, and Central America, south and southeast Asia, and sub-Saharan Africa, all within the 14–18% range.10 Biological, network, and structural level risks for HIV specific to MSM populations are driving these epidemics globally, and new, or newly identified, outbreaks are being detected wherever surveillance is undertaken. Achieving an AIDS-free generation will not happen unless new and effective approaches are developed and implemented at scale for MSM. And that will not happen if these men are excluded from health care and denied full social recognition and political engagement. Yet their exclusion is common in some settings, and systematic in others. This situation too must change. No population at risk for HIV infection can be excluded if we are to achieve control of AIDS worldwide.
