Research Article: Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review

Date Published: December 1, 2007

Publisher: Public Library of Science

Author(s): Stefan Baral, Frangiscos Sifakis, Farley Cleghorn, Chris Beyrer, Seth Kalichman

Abstract: BackgroundRecent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.Methods and FindingsA comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)–classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3–60.6); low-prevalence countries, 14.4 (95% CI 13.8–14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0–10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2–8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8–24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3–13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7–25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3–34.2); 18.7 (95% CI 17.7–19.7) for Asia; 3.8 (95% CI 3.3–4.3) for Africa; and 1.3 (95% CI 1.1–1.6) for the low- and middle-income countries of Europe.ConclusionsMSM have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. ORs for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium–high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.

Partial Text: Male-to-male sexual contact has been an important route of HIV-1 spread since HIV/AIDS was first identified some 25 years ago. HIV among gay, bisexual, and diversely identified men who have sex with men (MSM) remains a significant or predominant component of HIV epidemics in a number of high-income countries including the United States, Australia, and much of Western Europe [1]. In the United States and European contexts, high rates of HIV infection among younger and minority MSM have been seen by many as evidence of resurgent HIV spread [2,3]. Recent reports of high HIV prevalence among MSM from Asia, Africa, Latin America, and the states of the former Soviet Union (FSU) indicate that high levels of HIV infection among MSM are also being identified in several low- and middle-income countries [4–8]. Reports from Thailand, Cambodia, and Senegal, countries characterized by relatively low and declining HIV prevalence among heterosexual populations, but which have greater than 20% prevalence in MSM in recent samples, suggest an unlinked epidemic pattern between general population HIV rates and those in MSM [6,9–12].

This is to our knowledge the first meta-analysis of HIV survey data collected from MSM participants in low- to middle-income countries. Overall, the odds of having HIV infection are markedly and consistently higher among MSM than among the general population of adults of reproductive age across Asia, Africa, the Americas, and the FSU.



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