Date Published: May 31, 2019
Publisher: Public Library of Science
Author(s): Theo G. M. Sandfort, Karen Dominguez, Noel Kayange, Arthur Ogendo, Ravindre Panchia, Ying Q. Chen, Wairimu Chege, Vanessa Cummings, Xu Guo, Erica L. Hamilton, Michael Stirratt, Susan H. Eshleman, Jose A. Bauermeister.
Throughout the world, men who have sex with men (MSM) are at increased risk for HIV infection compared to heterosexual men. Little is known about awareness of HIV infection and other gaps in the HIV care continuum for MSM, especially in sub-Saharan Africa (SSA). This information is urgently needed to address the HIV epidemic in this population. This study assessed gaps in the HIV care continuum among persons screened for participation in a multi-country prospective study that evaluated the feasibility of recruiting and retaining MSM for HIV prevention studies in SSA (HIV Prevention Trials Network (HPTN) 075, conducted in four cities in Kenya, Malawi, and South Africa). Participants were recruited using site-specific strategies, that included outreach and informal networks. Transgender women (TW) were eligible to participate. During screening, 601 MSM and TW were tested for HIV infection and asked about prior HIV testing, HIV status, engagement in care, and HIV treatment. Viral load testing and retrospective antiretroviral (ARV) drug testing were performed for HIV-infected participants. Most participants (92.2%) had a prior HIV test; 42.1% were last tested >6 months earlier. HIV prevalence was 30.4%. HIV infection was associated with older age and identifying as female or transgender; 43.7% of the HIV-infected participants were newly diagnosed, especially younger persons and persons with a less recent HIV test. Almost a third of previously-diagnosed participants were not linked to care. Most participants (88.7%) in care were on ARV treatment (ART). Only about one-quarter of all HIV-infected participants were virally suppressed. These findings demonstrate substantial prevalence of undiagnosed HIV infection and sub-optimal HIV care engagement among MSM and TW in SSA. Increased HIV testing frequency and better linkage to care represent critical steps in preventing further HIV transmission in this population. Once in care, gaps in the HIV care continuum appear less critical.
As elsewhere in the world, men who have sex with men (MSM) in sub-Saharan Africa (SSA) are at increased risk for HIV infection compared to heterosexual men [1–7]. The observed HIV prevalence among MSM in SSA ranges from 7.8% in Khartoum, Sudan to 49.5% in Johannesburg, South Africa [1–3, 8–14]. Even though most countries in SSA have generalized HIV epidemics, HIV prevalence in men MSM, estimated to be 18% overall, is substantially higher (odds ratio = 3.8) than that of adult men in general [15, 16]. Furthermore, studies of the modes of HIV transmission show that while MSM constitute a relatively small proportion of the general population, their contribution to HIV incidence is substantial [17–20]. Modelling studies strongly suggest that addressing the HIV epidemic among MSM will substantially impact the general HIV epidemic in SSA . Information about HIV infection in transgender women (TW) in SSA is available from studies of MSM that also assessed gender identity. Using data from eight countries in SSA, Poteat et al.  concluded that the adjusted odds of HIV infection for trans women were 2.2 times greater than those for cis-gender MSM. Other studies reported similar findings [23, 24].
Of the 67 MSM&TW who reported that their last HIV test was positive and also tested positive at screening, 47.8% (32/67) reported that they were in care. The majority (81.3%, 26/32) of participants who reported to be in care also reported that ARV drugs had been prescribed. ARV drugs were detected in 88.5% (23/26) of the screening samples from these participants.
Although the majority of the MSM&TW screened for HPTN 075 reported that they had a prior HIV test, over a third reported that their last HIV test occurred more than 6 months prior to screening. Almost a third of all participants were HIV infected. The portion with HIV-infection was higher among older participants and among those who identified as female or transgender, even though testing frequency among TW was lower. Many of the HIV-infected participants were not aware of their positive HIV status; this was more likely the case among participants who reported that their last HIV test was less recent and among younger participants, who were also less likely to have had a prior HIV test. Almost a third of the participants who had previously been diagnosed with HIV infection reported that they were not engaged in care. The majority of the participants in care were on ART and the majority of those on ART were virally suppressed. The HIV care continuum gaps for HIV diagnosis and linkage to care explain why only 28.6% of all HIV-infected MSM&TW were virally suppressed (Fig 1).