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HIV Prevention Knowledge Base

A Collection of Research and Tools to Help You Find What Works in Prevention

Combination Approaches: Enhancing the Reach & Effectiveness of MSM-Targeted Combination HIV Prevention Interventions

I. Definition of the Prevention Area

Men who have sex with men (MSM) are globally disproportionately affected by HIV and urgently need increased coverage by quality prevention interventions. Evidence has shown that sustained combination approaches to HIV prevention that simultaneously address biomedical, behavioral and structural risks are most effective at reducing HIV transmission in generalized, concentrated, and mixed epidemic scenarios. Despite this evidence and the disproportionate epidemic burden MSM shoulder, HIV prevention services remain sub-optimal in many countries.

Not every MSM has an identity associated with their sexual preferences and behavior and therefore may remain non-self-identified, posing a formidable challenge to programs that seek to target them. For example, the term "MSM" can include gay- or bisexual-identified men, transgender men who have sex with men, men who identify as completely heterosexual, men who identify through indigenous identities outside the largely Western concepts of hetero- or homosexuality, or men with no particular sexual identity at all. In many cultures, heterosexism (the assumption that everyone is heterosexual) is pervasive, and any behavior or identity that deviates from a heterosexual cultural norm is stigmatized and discriminated against, and is in some cases criminalized.

Individual-level risks for HIV acquisition in MSM include unprotected receptive anal intercourse, a high frequency of male partners, a high number of lifetime male partners, injecting and non-injecting drug use, a high viral load in the index partner, and mental health issues. On the structural level, risks include criminalization of same-sex behavior, MSM avoiding health services out of fear of discrimination, and breaches of privacy and confidentiality. In order to succeed, HIV prevention interventions must address the complexities of MSM identity and take into account multiple levels of risk. Combination approaches that simultaneously address behavioral, biomedical, and structural risks are an effective way to do this. At all levels, MSM individuals and communities must be involved in the conceptualization, planning, implementation, and evaluation of research and programming.

II. Epidemiological Justification for the Prevention Area

Three decades into the epidemic, HIV continues to disproportionately affect MSM everywhere. Globally, MSM are 19 times more likely to be infected by HIV than the general population of reproductive age and have an overall HIV prevalence of 12%. Many MSM also have female sexual partners and can serve as a bridge to other populations. Despite these facts, research and interventions targeted at MSM are still under-prioritized by governments, donors, and civil society. Surveillance data, when available, is limited and likely underestimates both MSM population size and their HIV prevalence rates. Some estimates suggest that as low as 5% of MSM worldwide have access to basic HIV prevention services.

There is evidence to show that MSM-targeted prevention interventions can reduce risk for HIV infection among MSM. Group- and community-level behavioral interventions among MSM have been shown to lead to up to a 43% decrease in unprotected anal sex, and group-level interventions have been shown to increase the odds of condom use by as high as 81%. A recent study suggests that behavioral interventions that reach 25% or more non-self-identified MSM are more effective than those targeting self-identified MSM alone. Another study suggests that countries that combine MSM-specific community-based behavioral prevention interventions with condom and condom-compatible lubricant distribution can reduce new HIV infections among both MSM and the general population. Evidence also shows that episodic and/or single-track interventions tend to be less effective in the long-term, which highlights a need for sustained combination prevention approaches.

III. Core Programmatic Components

The World Health Organization (WHO), together with other global agencies, has identified a set of evidence-based, mutually reinforcing biomedical, behavioral, and structural HIV prevention intervention components which, when combined, effectively reduce HIV infection among MSM. The following are some examples of strongly-recommended program components:

  • Biomedical approaches aim to reduce HIV transmission and acquisition risk. Current approaches the WHO strongly recommends include condom distribution with silicone- and water-based lubricants combined with counseling and education, voluntary counseling and testing (VCT), sensitization of VCT sites to MSM needs, sexually transmitted infection (STI) screening and treatment (for genital, oropharyngeal and anorectal STIs) and antiretroviral therapy, including post-exposure prophylaxis (PEP). Though these are the current approaches, the combination prevention toolkit is growing with as more research is done around pre-exposure oral prophylaxis (PrEP) and rectal microbicides.
  • Structural prevention efforts aim to bring about social change in the general population by reducing stigma and discrimination and other barriers to effective prevention and treatment of HIV. Decriminalization of same-sex behaviors, policies that safeguard MSM and transgender rights, engagement with the media, and community and health systems strengthening are all examples of viable program components. However, none of these are unless communities are effectively mobilized, engaged, and empowered. Community members must be involved as a collaborative, iterative process. Moreover, evidence-based advocacy is an important step towards achieving positive structural change.
  • Behavioral approaches aim to promote safer behaviors to prevent HIV; specifically, sustained efforts to increase the use of condoms paired with water- and silicone-based lubricants, reduce the frequency of unprotected anal sex, and increase health-seeking behavior. Behavior change communication can effectively be delivered at individual, group and community levels and can include mobile phone messages, Internet-based strategies and social marketing campaigns; and other message delivery from diverse communication platforms, including sex venue "hot spots", health care facilities, and the general community.

MSM population size estimation is essential to prevention intervention program design. This poses a significant challenge, as many MSM do not self-identify or choose not to disclose their sexuality. A number of methods, including the relatively new network scale-up method, have shown effectiveness for use with MSM. UNAIDS recommends making estimates by triangulating results from more than one method and cautions that data should be interpreted with caution and sampling method biases should be clearly acknowledged. Finally, more research should be done on the viability of all methods for use with MSM.

IV. Current Status of Implementation Experience

Regardless of which combination of prevention approaches is used, a number of overarching best practices are recommended to improve the reach and quality of all MSM-targeted HIV programs:

  1. 1. Involve MSM and MSM living with HIV in program design, implementation, and evaluation. The most deep-reaching and successful approaches to prevention interventions leverage community ties and experiences; their networks, an understanding of risk-related issues, and their ability to meaningfully connect with other MSM.
  2. 2. Ensure confidentiality. Given the high levels of stigma and discrimination MSM face, confidentiality is a key requirement.
  3. 3. Provide training for both general healthcare staff and staff who work in HIV prevention, care and treatment programs to help them provide quality, stigma-free services.
  4. 4. Reach beyond MSM groups. Interventions that target general audiences in addition to MSM audiences have been shown to also reach diverse subgroups of MSM, including non-self-identified MSM.
  5. 5. Collect and use strategic information such as ongoing surveillance, research studies, and monitoring and evaluation data, and incorporate new knowledge and technological advances as they emerge.
  6. 6. Link, integrate and co-locate services, especially to HIV care and treatment for HIV-positive MSM. This is particularly important, as anti-retroviral therapy has been identified as a key component of successful HIV prevention.

Although many studies demonstrate the reproducibility of research and the effectiveness of behavioral interventions with MSM in the United States, far less information is available for program outcomes in other geographic areas, such as Africa and Asia, and among hard-to-reach subgroups of MSM. To inform future interventions, more investment must be made in conducting research in these other contexts and publishing findings widely.