The Lancet MSM and HIV series show us that HIV epidemics among MSM are fundamentally different from other groups at risk. These differences help explain why HIV epidemics among MSM expanding in low, middle, and high income countries, including the U.S., and why current HIV prevention and treatment programs for MSM are not working as well as they should. Biological, network, and social/structural factors combine for MSM and lead to more rapid and efficient HIV spread in MSM communities—individual risk behaviors for HIV infection contribute only modestly to these dynamics.
New and more effective HIV prevention programs for MSM must reduce infectiousness through markedly expanding testing and treatment of positive men, and reduce risk of acquisition among negative men, through the use of PrEP, the development of a rectal microbicide, and increased access to and coverage for condoms and condom-compatible lubricant. Current prevention tools could reduce new HIV infections in MSM substantially, but more and better tools will be needed to achieve an AIDS free generation for young MSM. Stigma, discrimination, and social and health care level homophobia
continue to limit access and uptake to essential services from testing to treatment, and from condoms to PrEP. Policy reform and structural changes will be key to expanding coverage and reaching men with culturally competent care. These realities are most clearly demonstrated among minority MSM in the U.S., where black MSM have much higher rates of HIV infection then other MSM, despite having lower individual risks for HIV. But black MSM also have lower rates of testing, health care access, health insurance, and successful HIV treatment—impacts seen at each step of the treatment cascade. Urgent reform is needed, in approaches, programs and policies, if we are to make real gains against HIV among MSM. Future efforts must be more biologically based, focus on delivery of effective interventions, address each gap in the testing to treatment cascade, and ensure safe and affirming spaces for prevention, treatment, and care.
In 2012, HIV epidemics in MSM are expanding in countries of all incomes. Available
incidence data from Thai, Chinese and Kenyan samples of MSM suggest those epidemics
are in rapid expansion phases.
HIV infection rates among MSM are substantially higher than those of general population adult males in every epidemic assessed. A comprehensive review of the burden of HIV disease in MSM worldwide found that pooled HIV prevalence ranged from a low of 3% in the Middle East and North Africa to a high of 25.4% of MSM in the Caribbean.
Biological and behavioral factors make the dynamics of the MSM epidemic different than for general populations.
The disproportionate HIV disease burden in MSM is explained largely by the high per act and per-partner transmission probability of HIV transmission in receptive anal sex.
Modeling suggests that If the transmission probably of receptive anal sex was similar
to that associated with unprotected vaginal sex, five year cumulative HIV incidence in
MSM would be reduced by 80-90%.
o Many MSM practice both insertive and receptive roles in sexual intercourse, which
helps HIV spread in this population. Were MSM limited to one role, HIV incidence in
this population over five years would be reduced 19-55% in high-prevalence
o Taking both factors (per act transmission probability and role versatility) into
account explains 98% of the difference between HIV epidemics among MSM
and heterosexual populations—behavioral differences account for 2% of the