HIV/AIDS Epidemics Among MSM In Developing Countries

1. HIV/AIDS Epidemics Among MSMIn Developing Countries AMFAR: HIV Prevention among MSM August 17, 2006 Toronto Chris Beyrer MD, MPH The Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health

2. Introduction • HIV epidemic spread among MSM is occurring in both high and low income settings in 2006 • Developing country epidemics are underway in Latin America, Asia, Eastern Europe/FSU, and Africa • Many MSM epidemics are occurring in “hidden” contexts of discrimination, stigma, criminalization, limited HIV surveillance • US and UK MSM epidemics are significantly more severe among Black MSM—”The Global South”

3. Global HIV Prevalence Trends in MSM

4. HIV prevalence among MSM in low prevalence settings Source: Wade et al. 2005; Girault et al. 2004; van Grievsven et al. 2005; Action for AIDS Singapore, 2006, Go et al. 2004; Pando et al. 2006; UNAIDS, 2006; Caceres et al, 2005, Strathdee, et al, 2006. CENSIDA, CA State Office of AIDS; Patterson et al, IAS, 2006; Strathdee et al, pers. comm; Viani et al, 2006

5. HIV prevalence among MSM, Bangkok, Thailand 2003 40 2005 35 30.5 29.7 28.3 30 25 22.3 HIV Prevalence (%) 20.8 20 17.5 17.3 15 12.9 10 5 0 Age (years) ≥29 ≤22 Overall 23-28 N = 194/1,121; 113/399 p-values all < 0.05 Source: Van Griensven, et al, MMWR. 2006

6. HIV prevalence among MSM, Bangkok, Thailand 2003 – 2005, by recruitment venue % HIV infected 2003 2005 Entertainment Park Sauna Overall Recruitment venue

7. Argentina Ecuador Bolivia Paraguay Peru Chile Colombia Uruguay Venezuela HIV prevalence (%) among female sex workers and MSM in Latin America, 1999–2002 Quito Buenos Aires Provinces (7 cities) Guayaquil La Paz Other city ports (4) Asunción + 4 cities Santa Cruz Border cities with Argentina Lima 0.0 Santiago Provinces Bogotá Montevideo Border cities with Brazil 0 5 10 15 20 25 30 0.0 % HIV prevalence Isla Margarita 0 5 10 15 20 25 30 % HIV prevalence Female sex workers MSM Source: Montano SM et al., JAIDS (2005).

8. HIV prevalence in selected high risk groups: Mexico-U.S. Border States 15.5% 16 14.5% 14 12 10 8% 8 6% 6 4 1% 2 0 MSM Male CSW Female CSW IDU Pregnant women Sources: CENSIDA, CA State Office of AIDS; Patterson et al, IAS, 2006; Strathdee et al; Viani et al, 2006

9. HIV Prevalence Trends in the US: Black MSM at Risk

10. % Δ / year 20000 2.7 MSM 15000 −3.9* HC HIV / AIDS 10000 IDU −9.1* 5000 −3.4* MSM/IDU 0 2001 2002 2003 2004 Year of Diagnosis Estimated Number of HIV/AIDS Diagnoses, by Transmission Category — 33 States, 2001–2004. * Statistically significant Source: Espinoza, CDC, 2005

11. HIV/AIDS and MSM in the U.S.

12. Characteristic Total Tested HIV Prevalence N (%) Undiagnosed HIV Infection N (%) Total 1767 450 (25) 217 (48) Age 18-24 25-29 30-39 40-49 ≥ 50 410 303 585 367 102 57 53 171 137 32 (14) (17) (29) (37) (31) 45 37 83 41 11 (79) (70) (49) (30) (34) Race White Black Hispanic API NA/AN Multiracial/Other 616 444 466 95 <10 123 127 206 80 7 <10 25 (21) (46) (17) (7) (29) (20) 23 139 38 2 <10 13 (18) (67) (48) (29) (100) (52) HIV Prevalence and Proportion with Undiagnosed HIV Infection in MSM in 5 Cities – NHBS, 2004-2005 MMWR: 2005; 54(24)597-601

13. Black MSM in the US: Hypotheses for higher HIV rates Not Supported • More high-risk sex • Less “gay” identified → more risk • More drug use, more IDU risk • Supported • More STI: Syphilis, GC, NGU • Less often HIV tested, less likely to know status • Insufficient data • circumcision • sexual Networks may increase risks (1 + study) • incarceration → more HIV risk (1 + study) Source: Millett, et al, AJPH 2006

14. Prevalence of Noninjection Amphetamine or Methamphetamine Drug Usage in the Preceding 12 Months, by Race/Ethnicity and HIV Serostatus Drake A, CDC, Toronto, 2006

15. Racial Differences in HIV Seroprevalence among MSM in developed nations Source : CDC, 2005; Dougan et al. STI, 2005

16. Risk Factors Driving MSM Epidemics

17. Individual Level Associations for HIV among MSM Unprotected Anal Intercourse - Thailand Unprotected Anal Intercourse - Brazil Uncircumcised - US Frequency of Partners (>3/week) - Peru Lifetime Partners (>10) - Senegal Lifetime Partners (>10) - Cambodia Injection Drug Use - Brazil Black/African American - US Methamphetamines - US Poppers - US Sources Beyrer et al. 2005, Ferreira et al. 2006, Bautista et al. 2004, Wade et al. 2005, Girault et al. 2004, Koblin et al. 2006, Harawa et al. 2004, Buchbinder et al, 2005

18. MSM structural risk contexts • Criminalization and stigma limit MSM access to HIV prevention, treatment and care • MSM understudied in emerging contexts: MSM not included in national HIV surveillance in Thailand, Vietnam, Senegal • Only one African study (Wade, et al) of MSM risk and HIV rates • Fewer than 1 in 10 MSM worldwide have access to necessary prevention services Sources: UNAIDS; USAID, 2004; Wade 2005; Go 2006 personal communication; HRW; UNAIDS 2006

19. MSM Risk and Rights Contexts • “Vulnerability to HIV infection is dramatically increased where sex between men is criminalized.” • UNAIDS, 2006 • Criminalization and homophobia limit MSM access to HIV prevention information commodities, treatment and care. • USAID, 2004 • MSM behavior is criminalized in more than half of all African States • 2006 review of the literature found no African studies of the prevalence of MSM behavior, and that few behavioral studies included questions on MSM • Caceres, et al, STI 2006 • Faced with legal or social sanction MSM are excluded, or exclude themselves from sexual health and welfare • UNAIDS 2006

20. India May Scrap Gay Sex Law Over HIV Fear NIRMALA GEORGE (AP, July 26, 2006) • Health authorities call for repeal of law that makes gay sex a crime, fearing it is causing HIV spread • The National AIDS Control Organization, NACO, argued law creates a public health risk • "So long as the gay community is forced to go underground, it limits the access to them and makes it difficult for the AIDS prevention campaign to reach them," -- Sujatha Rao, NACO • 1861 law makes consensual sex between same-sex adults punishable by up to 10 years in prison. Prosecutions rare under the law, but activists say police use it to harass • NACO : estimated 8% of India's MSM HIV infected in 2005 • In May, 2006 UNAIDS reports India has the world's largest number of people living with HIV: 5.7 million

21. Ecological Model for HIV Risk in MSM HIV Epidemic Stage Criminalization, Homophobia, Human Rights Contexts, Condom Availability, Exluded from National Surveillance, Sexual Health Education Lack of preventive services, Stigma, VCT Access, ARV Access STI Prevalence, Condom Availability, Receptive or Insertive Intercourse Unprotected Receptive Anal Intercourse, GUD, Lack of circumcision, frequency of male partners, high lifetime partners, IDU, poppers, meth, Black/African American Individual Risks for HIV Infection Widening Risk Contexts for HIV Infection

22. MSM Epidemics in 2006 • HIV continues to disproportionately affect MSM in high and low income settings, and among minority men in US/UK • MSM outbreaks in Africa, Asia and Latin America are occurring against low backgrounds of HIV infection in general populations and are markedly understudied • UNAIDS estimates that less than 1 in 10 MSM worldwide have access to necessary prevention services