Globally, gay men and other men who have sex with men (MSM) have a 27 times higher risk of HIV infection compared to the general population (UNAIDS, 2018).
According to a UNAIDS (2017) study in about 25 countries, more than 15% of men who have sex with men are living with HIV.
Even in countries where same-sex relationships are legal, there are other laws that discriminate against LGBTQ people, and stigma and discrimination prevent them from accessing HIV services, leading to increased risk behaviors that foster HIV transmission.
What factors put men who have sex with men at risk of HIV infection?
The fact that HIV prevalence among MSM is so high in so many countries puts MSM at risk of exposure to HIV. This is mainly due to unprotected sex (CDC, 2018). However, there are other factors that put men who have sex with men at risk for HIV infection.
Biological factors
One of the key reasons for increased vulnerability to HIV infection among this group is that unprotected anal sex poses a higher risk of HIV transmission than unprotected vaginal sex. The reason is that the walls of the anus are thin, which favours the creation of sores and thus a gateway for HIV to enter the bloodstream. (CDC, 2018)
A person who already has an active sexually transmitted infection (STI) is more susceptible to HIV infection. Rates of STIs among men who have sex with men are very high and have steadily increased over the past 20 years.
Despite these increased biological risks, HIV testing and frequency of sexual health surveillance remain relatively low among this group (less than 55% in all regions in 2013) (UNAIDS, 2014).
Multiple studies in different countries have shown that men who have sex with men fear discrimination, moral judgement, mistreatment, and fear that their privacy may be violated in the health care setting. As a result, many MSM live with an undiagnosed STI, which can greatly increase their risk of HIV infection.
There is a particularly high risk of HIV transmission if someone has had unprotected sex with a newly infected person. For example, a study in London reported that 27% of infections among MSM were from a partner who was newly diagnosed with HIV. However, many men who have sex with men don’t know this. (The Lancet, vol 380, issue 9839, p 340)
Behavioral factors
Having multiple sexual partners is common among men who have sex with men, yet many do not use condoms. In 33 countries, less than 60% of men who have sex with men reported using a condom at last anal sex, and only 15 countries had rates higher than 80%. (UNAIDS 2018)
Data on other STIs among MSM is further evidence of condom non-use.
Access to HIV testing services among MSM is also low. Lack of services tailored to the needs of this group leads to unawareness of status and lack of awareness of the need to take protective measures.
Alcohol and drug use is commonly seen as part of socialization in some communities of men who have sex with men. Being under the influence of drugs or alcohol increases the chances of men having unprotected sex and sex with multiple partners, increasing the risk of HIV transmission. (UNAIDS 2017)
Health professionals are particularly concerned about the high-risk behaviors that drug use fosters; lack of inhibition and physical awareness can often lead to having unprotected sex with multiple partners or sharing injecting equipment, all of which increase the risk of HIV transmission.
Men who have sex with men often find out they are HIV-positive at a very young age. Estimates suggest that 4.2% of young MSM (under 25) are living with HIV (WHO 2015). This is more common in countries where HIV prevalence among adult MSM is relatively high.
Young men who have sex with men find it harder to access HIV testing services, due to consent laws or unfriendly testing center schedules.
Social and cultural factors
Many men who have sex with men have faced stigma, homophobia, discrimination and violence. This leads them to hide their sexual identity and orientation. Many fear a negative reaction from medical professionals. As a result, men who have sex with men are less likely to access HIV services than heterosexual men.
Men who have sex with men are more likely to become depressed due to social isolation and to be rejected by health systems. This can make it difficult for them to adhere to HIV drugs. (UNAIDS, 2017)
HIV prevention programmes for men who have sex with men
Looking at the high prevalence of HIV in MSM communities around the world, it is clear that prevention strategies are failing to reach this group.
When men who have sex with men are targeted by HIV prevention campaigns, the results can be very rewarding. It is important that a variety of prevention programmes are available.
Condoms and lubricants
One of the most important ways of prevention is to make condoms and water- or silicone-based lubricants available and affordable for MSM.
In some countries, gay bars and other known venues for men who have sex with men, such as saunas, provide and promote condoms and lubricants. This is also the case in Romania, in clubs such as Q Club (Bucharest) or Delirio (Cluj). In most cases, providing condoms and lubricants in gay-friendly venues is much more effective than expecting men who have sex with men to buy them from pharmacies, where various barriers (e.g. shame) can intervene (PEPFAR 2011).
Community involvement and empowerment
Some of the most successful HIV programmes targeting men who have sex with men are community-based and often community-led initiatives. These are services and interventions that are designed and, delivered to men who have sex with men in locations where people feel comfortable.
It has been shown that training MSM and involving them in HIV prevention campaigns that provide prevention materials (condoms, lubricants, etc.) and linkage to services effectively reaches and engages this population and significantly reduces HIV transmission rates.
This prevention strategy works because there is a greater sense of trust between MSM and their peers, thus decreasing fears of stigma.
Use of technology
Due to the preference for anonymity when it comes to accessing health services, some studies have shown that technology and online social media have helped provide HIV prevention information to men who have sex with men.
Access to antiretroviral treatment for men who have sex with men
There are not enough statistics that accurately show men who have sex with men’s access to HIV treatment. However, existing evidence suggests relatively limited access.
Globally, only 40% of MSM living with HIV are thought to access treatment. Those in low- and middle-income countries generally report the lowest rate of access to antiretroviral treatment (ART), particularly in countries that punish homosexual sex. (AIDS and Behavior, vol. 19, no. 2, p.227-234) Reasons cited for this low rate of access include homophobia, stigma and discrimination. These are factors that lead to delay, interruption or complete avoidance of treatment. Reactions from medical staff are also cited as a reason.
Studies also suggest that minorities within MSM groups may experience complex discrimination, and this, associated with low self-esteem, is inversely related to use of medical services as well as compliance with medical appointments.
Barriers to accessing HIV prevention programmes for men who have sex with men
High-risk sexual behavior
Many men who have sex with men want to keep their sexual orientation secret because of the associated stigma and will, in many cases, continue to have heterosexual relationships.
Many men who have sex with men perceive their risk of HIV infection as very low because they have not had contact with prevention initiatives and the subject is not included in health education classes in school.
Having multiple partners is a common situation among MSM, which, combined with alcohol and drug use, increases the likelihood of engaging in high-risk sexual behaviors such as not using condoms.
Stigma, discrimination and violence
The gender norms of many cultures do not accept men who have sex with men. As a result, a large proportion of MSM around the world have reported experiencing violent abuse because of their sexual orientation. This is especially evident in patriarchal societies.
In some areas, public administration, police, and medical personnel commit these actions. Fear of being identified as gay prevents many men from accessing HIV services, avoiding routine health checks and accessing treatment to keep their orientation secret.
Evidence also shows that, under certain conditions, a large proportion of men who have sex with men also experience intimate partner violence. A survey of MSM PrEP users in the UK found that about 45% of them had experienced intimate partner violence and about 20% of them had been perpetrators. (BMC Public Health, vol. 19, no. 1, p.431)
Lack of studies
Although some statistics provide a clue about the impact of HIV on men who have sex with men, data are still extremely scarce in many countries. This is largely due to the fact that MSM are often simply considered part of the general population.
It is also due to the reluctance of many governments to accept the existence of men who have sex with men and the lack of interest in monitoring this group. As a result, data on HIV among men who have sex with men is lacking, especially in regions such as Eastern Europe and Central Asia.
Lack of funds
Most HIV services for men who have sex with men in low- and middle-income countries are supported financially from international sources and less from domestic funds. In 2013, only 11% of funding for these services globally came from domestic funds (UNAIDS 2013).
Even in countries where the rights of MSM are legally and formally respected, there is generally a greater need for funding from donors and governments, as funding for prevention services is often insufficient compared to the scale of the problem. As is the case in Romania.
For the future
Evidence shows that providing HIV and AIDS services to those most at risk of infection can be highly beneficial to the HIV/AIDS strategy of an entire country. It is important that all governments and international donors seriously address the current neglect of the HIV epidemic among men who have sex with men. Not only is funding needed for HIV prevention, testing and treatment, but also research and statistical data to inform the population as effectively as possible. Without funding for research and programme implementation, HIV prevalence among men who have sex with men will remain high.
Stigma and cultural differences in same-sex relationships are often the reasons for the increase in the number of infections. Until these issues are addressed, it will continue to be difficult to reduce HIV infection among MSM. Global and community change is needed to end stigma and discrimination on the issue of homosexuality.