Global information and education on HIV and AIDS

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One apostle thought all men should go to farming, and another that no man should buy or sell, that the use of money was the cardinal evil; another that the mischief was in .
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Men who have sex with men are more likely to experience depression due to social isolation and disconnectedness from health systems. This can make it harder to cope with aspects of HIV such as adherence to medication. High HIV prevalence among men who have sex with men around the world is evidence that prevention strategies are failing to reach this group.

However, access varies greatly between regions and within countries. For example, men who have sex with men on a higher income are more likely to be able to afford, and therefore access prevention initiatives, than those on a low income. When men who have sex with men are targeted by HIV prevention campaigns they can be extremely effective.

It is important that a combination of prevention programmes are available. In recognition of this, in , a group of international agencies and non-governmental organisations NGOs released a tool for use by public health officials, HIV and STI programmes officials, NGOs both international and community-based and health workers.

One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible to men who have sex with men. In some countries, gay bars and other known meeting places for men who have sex with men, such as bathhouses, provide and promote condoms and lubricants.

The Blue Sky Club is a civil society group in Vietnam that provides 'edutainment' events in local bars and clubs, combining HIV education and condom distribution with entertainment, which are well received by local men who have sex with men.

The most successful HIV programmes aimed at men who have sex with men empower this group and actively involve them in a community setting. In sub-Saharan Africa, studies have shown how HIV services that are targeted at, and run by men who have sex with men, have seen the greatest response and uptake.

Training peers who are part of the men who have sex with men population to educate others, provide prevention commodities and link people to MSM-friendly HIV services has been shown to effectively reach and engage this population.

This prevention strategy works on the basis that there is an elevated sense of trust between members of the men who have sex with men population, whereby fear of stigma is eradicated.

Two of the most effective ways to encourage HIV testing among men who have sex with men are to permit home-based testing, and provide community-based testing. Home-based testing has the benefit of the user being able to avoid identification by healthcare workers. Another study conducted in Australia found that HIV self-testing doubled frequency of testing among men who have sex with men at high risk of HIV, and quadrupled the frequency among non-recent testers, compared with standard care.

It also showed that the availability of self-testing kits did not reduce the frequency of facility-based HIV testing. HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. Men who have sex with men should be educated about the use of self-testing kits, to heighten their confidence in using one as an alternative to testing at regular healthcare settings.

Community-based testing at local pop-up clinics or mobile vans is also favoured among men who have sex with men. It means that they can access testing in a setting they are comfortable in, without having to travel to clinics where they may be seen or experience discrimination.

PrEP is a single pill taken every day by people who are at risk of HIV exposure, such as men who have sex with men. As of , some level of PrEP access had been approved in over 60 countries. This is double what it was in and is expected to continue to grow. There are indications that, where individuals have been able to access it, PrEP has had considerable success in preventing new HIV infections among men who have sex with men, even in countries where it is not available within national healthcare systems.

This has been attributed by several clinics to the purchasing of generic PrEP online, as the decline in new infections coincided with a rapid increase in the number of men buying PrEP online. I Want PrEP Now says that 2, men have been purchasing generic PrEP through its website, and services offered by several clinics to test for drug concentrations and adverse events related to PrEP have been well used. The decline in infections cannot with certainty be linked to PrEP, but the correlation of these factors is compelling.

In order for PrEP to provide effective prevention it must be taken correctly and consistently. PrEP does not provide protection against STIs, and if not taken consistently is much less effective, so does not replace other prevention options like condoms. It must also be coupled with counselling about the importance of finishing the treatment course. Due to the preference for anonymity when it comes to accessing healthcare, some studies have shown that technology, messaging, and social media have helped to provide HIV prevention information to men who have sex with men.

One study in South Africa found that sending text messages to men who have sex with men over a period of time encouraged men to test for HIV. These types of programmes should be further explored as an avenue to engage men who have sex with men in the HIV response and their own healthcare.

Accurate statistics comparing treatment access among men who have sex with men is rarely available but, when it is, limited uptake is frequently shown. Those living in low- and middle-income countries generally report the lowest access to ART, with especially low rates in countries which criminalise same-sex behaviour.

Reasons cited for such low access include homophobia, stigma and discrimination. These can cause men who have sex with men to delay, interrupt or avoid treatment altogether. Experiencing these reactions from healthcare workers is also given as a predominant reason. However, ingrained cultural stigma has also been found to impact access to treatment among men at risk of HIV in high-income countries too.

Drop-off was particularly dramatic among young men who have sex with men and men who have sex with men in lower-income countries. This was due to a lack of investment and youth-friendly services. By contrast, comfort with provider, more community engagement and better accessibility of ART were associated with higher retention rates in care. Due to widespread stigma, many men who have sex with men want to keep their sexual orientation secret, and may also continue to have heterosexual relationships and even get married.

Having multiple partners is also more common among this community, with alcohol and drug abuse increasing high-risk sexual behaviour such as not using a condom.

Where there are laws that criminalise same-sex sexual relations, governments are unlikely to promote any sort of HIV interventions aimed at men who have sex with men. As a result, men who have sex with men living in these countries are unaware of their risk of HIV, can be turned away from HIV services, are fearful of accessing HIV testing, and find it difficult to get hold of condoms and lubricants.

A huge proportion of men who have sex with men worldwide have reported experiencing violence due to their sexual orientation. This is especially evident in machismo cultures, and patriarchal societies such as those in Latin America. In some areas, it is public officials or even healthcare workers that are committing these offences. The fear of being identified as homosexual deters many men from accessing HIV services, avoiding healthcare check-ups and treatment in order to keep their orientation secret.

Although some statistics give an indication of the impact that HIV is having on men who have sex with men, data is still extremely scarce in many countries. This is largely due to the fact that men who have sex with men are often simply counted as part of the general population.

It is also due to the reluctance of many governments to acknowledge men who have sex with men, and monitor this group. This reflects the punitive laws that criminalise same-sex behaviour in the region, and an unwillingness of governments to accept that there is a disproportionate epidemic emerging among this population. It has been suggested that in settings where men who have sex with men are a particularly stigmatised group, collaborations between the government and NGOs are the most effective way to reach this population.

The frightening truth is that, in many parts of the world, we simply do not know how bad the epidemics among MSM groups may be… transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts. Apart from a handful of countries such as Brazil and Cuba, the majority of funding for HIV services targeted at men who have sex with men comes from international sources rather than domestic funding.

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