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The Persistent and Evolving HIV Epidemic in American Men Who Have Sex With Men

Dr. Matthew Mimiaga, UCLA Fielding School of Public Health professor of epidemiology, co-authored a research piece in the journal The Lancet on the ongoing HIV epidemic in this population, using a social-ecological perspective

Friday, February 19, 2021

Dr. Matthew Mimiaga, UCLA Fielding School of Public Health professor of epidemiology, co-authored a research piece in the journal The Lancet on the ongoing HIV epidemic in this population, using a social-ecological perspective.

Summary: Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortativemixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negativeinteractions with the health-care system.

Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.

Conclusions: Our review has identified several common factors that potentiate the HIV epidemic among all MSM in the USA, including biological vulnerability, unique network characteristics, and internalisation of societal stigma leading to behavioural syndemics, enhanced by the disinhibiting effects of substance use. Growing up in non-affirming environments has health consequences. However, our review has also established that diverse subgroups of MSM exist, with unique racial, ethnic, age- related, and gender identities and needs. Institutional racism and cultural insensitivity will potentiate the increasing disparities in HIV incidence and access to optimal treatment and prevention services. Interventions that can leverage advances in antiretroviral-based treatment and prevention to curtail the domestic epidemic in US MSM will need to attend to the common themes (eg, by integrating behavioural health services with biomedical interventions), but culturally tailored programmes need to be developed to address the specific drivers of HIV risk in the diverse but vulnerable subpopulations. Interventions will need to attend to structural issues, including racism, poverty, homophobia and transphobia, and understand how different age cohorts meet partners and access health information, by considering how to educate and engage MSM in the digital era.

Although great progress has been made in recent years, almost half of people with HIV in the USA are not currently virally suppressed on highly active ART, and fewer than a quarter of MSM in the USA who might benefit from PrEP are using it. The disparities in accessing the benefits of therapeutic and preventive advances are particularly egregious for Black and Latino MSM, indicating that much more work remains to be done to develop effective, culturally congruent programmes to addresss these challenges. In the face of many adversities, MSM in the USA have shown resilience, but progress will not happen unless structural and societal issues (eg, racism, access to health insurance, culturally responsive care) are properly addressed.