High HIV prevalence among gay men around the world is evidence that prevention strategies are failing to reach this group.
Reports from 20 countries in 2009 and 2013 show that the percentage of gay men reached by HIV prevention programs fell from 59% to 40%. However, access varies greatly between regions and within countries. Men who have sex with men on a higher income are more likely to be able to afford, and therefore access prevention initiatives.
When gay men are targeted by HIV prevention campaigns they can be extremely effective. It is important that a combination of prevention programs are available.
In recognition of this, in 2015, a group of international agencies and non-governmental organisations (NGOs) released a tool for use by public health officials, HIV and STI programmes officials, NGOs (both international and community-based) and health workers.
The tool, Implementing Comprehensive HIV and STI Programmes with Men Who Have Sex with Men [pdf], provides recommendations for HIV prevention, testing and treatment for men who have sex with men and is based on successful community-led approaches.
Condoms and lubricants
One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible.
In some countries, gay bars and other known meeting places, such as bathhouses, provide and promote condoms and lubricants. The Blue Sky Club is a civil society group in Vietnam that provides ‘edutainment’ events in local bars and clubs. Combining HIV education and condom distribution with entertainment, which are well received by local gay men. Providing condoms and lubricant in gay-friendly places is much more effective than expecting gay men to purchase them.
The most successful HIV programs aimed at gay men empower this group and actively involve them in a community setting.
In sub-Saharan Africa, studies have shown how HIV services that are targeted at, and run by gay men have seen the greatest response and uptake. This avoids the necessity of attending general healthcare settings. Gay men feel risk of identity and sexual orientation exposure that could be met with stigma and discrimination.
Training peers who are part of gay men to educate others, provide prevention commodities and link people to MSM-friendly HIV services has been shown to effectively reach and engage this population.
Tthere is an elevated sense of trust between gay men whereby fear of stigma is eradicated. Organisations staffed by gay men are also more credible and accessible to recipients
In the Philippines, one initiative attempted to help civil society engage with local government in the HIV response. Eighteen community-based groups were set up and 200 gay men who and transgender people were trained in sexual health and rights. After three years, community leadership led to dialogue with local government officials on HIV, gender and human rights issues. One outcome of this process was an anti-discrimination ordinance in the city of Cebu in 2012. It prohibits discrimination on the basis of sexual orientation, gender identity and health status (including HIV).
HIV testing initiatives
Two of the most effective ways to encourage HIV testing among gay men are to permit home-based testing Also to provide community-based testing.
Home-based testing has the benefit of the user being able to avoid identification by healthcare workers. The privacy of conducting an HIV test alone at home makes this an appealing option for gay men. One study in Brazil found that 90% of gay men participants would use self-testing kits. Concerns included receiving the result alone and being able to read the result properly.
Study conducted in Australia found that HIV self-testing doubled frequency of testing among gay men at high risk of HIV. It quadrupled the frequency among non-recent testers, compared with standard care. It also showed that the availability of self-testing kits did not reduce the frequency of facility-based HIV testing.
HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. Men who have sex with men should be educated about the use of self-testing kits, to heighten their confidence in using one as an alternative to testing at regular healthcare settings.
Community-based testing at local pop-up clinics or mobile vans is also favoured among gay men. It means that they can access testing in a setting they are comfortable in, without having to travel to clinics where they may be seen or experience discrimination.
PrEP is a single pill taken every day by people who are at risk of HIV exposure. Research has shown that pre-exposure prophylaxis (PrEP) can reduce HIV transmission among gay men by 92%. The World Health Organization (WHO) states that if its use is scaled up, an estimated 20% to 25% of new HIV infections could be prevented. Despite expanding evidence of its effectiveness in HIV prevention, access to PrEP remains limited. As of June 2017, some level of PrEP access had been approved in over 60 countries. This is double what it was in 2016 and is expected to continue to grow.
In order for PrEP to provide effective prevention it must be taken correctly and consistently. Gay men should be counselled and informed about the correct use of PrEP before it is offered. PrEP does not provide protection against STIs. If not taken consistently is much less effective, so does not replace other prevention options like condoms.
Post-exposure prophylaxis (PEP) is taken after potential exposure to HIV. WHO recommends offering PEP to gay men as part of a package of prevention options. It must also be coupled with counselling about the importance of finishing the treatment course. One study found that only 67% of gay men on average completed the 28-day course.
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